ETApplication # ~ 2 2 ZI
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR 1111 W 1 MEN
, ',1FIRE-9AMA-GF1,
NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OFAPPLICATION.
Date: I - 3) - Oct
Proposed Buyer or Business Name:
Applicant/Mortgage Co:
Mailing Address:
City:
Telephone
Current Land Owner:
Property Address:
State:
Other ( )
Zip:
Phone: 9 /D - ~ S/ - G'l/,
PIN:---Q b S~ - fq - y i 5"0 . Parcel: n 770 bk~ O 1 Z q Z Fl
State Road State Road Name: R' , JY t b, rclh
Name of Subdivision: -e i c~ Lot #-z 3 (If Applicable)
n un uyc or c ren
W t: AX e 160F
aye s hours:
Directions: (please give concise, complete directions from Lillington, NC to the property)
*1 ~.o \1 A 'CV OVVN 'R e. C( e,k
T 4- 0 h 13,11 Ao
T-L
1?. 3-
There is a $100.00 charge for this service. This approval is subject to revocation if the
intended use of the septic system changes or if false information is provided on this
application.
Your signature below, certifies that all above information is Corr t.
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signature of Environ tal Heal Specialist Date
SEPTIC I P1 , r on --7 AMR