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ol 09 CY6 Application #
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits
:CATION FOR EXISTING SEPTIC SYSTEM INSPECTION
0
RE DAMAGE, ETC. J
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NOTE- A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF A TI ON.,
Date: A~ q , 5 C"o c f/ ic~a _ 1 qb, o? ooq
Mailin N(
City:
Telephone:
State:_
Other (119
Current Land Owner: t
AC4~~v 17
Phone: ~1
Property Address: 0C Ivi I I A M 5,
PIN: QS 5 - l U arcel: 015!E;1, a
State Road a State Road Name: l2d
Nance of Subdivision: - Lot # (if Applicable)
There is a 00@10beharge for this service. This approval is subject to revocation if the
intended use of the septic system changes or if raise information is provided on this
application.
Signature of Owner, Authorized Agent or
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
/0 9
Signature of Enviiro ental Health Specialist Date
• SEPTIC
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dud a. Act
4/08
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Your signature below certifies that all above i