ET
POt s e.. rus)-, / f
sst b(~ Application # 00( 5 0 D
COY
HARNETT COUNUT Y CENTRAL PERMITTING 102'0
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE COMPANIES COM!
IER OF,
NOTE: A~D/EED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: 11 l / 6 J
L. Proposed Buyer or Business Name: V/ V :774e, Applicant/Mortgage Co. T`
Mailin Addr ss:
City: State:
Telephone: ( ) Other Zip: .2 7 S g~ z
Current Land Owner: , Property Address: / e i r
PIN:~i~1(o--99-1891 000 Cam!/ av~a 5'i fs
State Road Parcel: 03OSDI 02Ay a 4a <u 2, ~
State Road Name;
Name of Subdivision: D,,/ SE c jt 3 Lot # 2
(If Applicable)
Da care: # of employee's ~~:.s y n
Restaurant: # of Hours
'°`r'Pn'1GCS # of scats
Directions: (please give concise, complete directions from Lillie on NC "I'll" l l ell',
tot le property)
421-
'4711 a ~avta 7'ctc~
112
~O Q' C3 ~i e /~f G~ G rG e~ L Q 7 ~u
There is a X100.00 charge for thi e ? A.
s service, This approval is subject to revocation if the N
intended use of the septic system changes or if false information is provided on this (a a' re
application.
Your signature below certifies that all above information is correct.
Signature of Owner, Authorized Agent or Applicant: G?'-y>~C S - o j'
FOR OFFICE USE ONLY
TION FOR USE OF EXISTING SEPTIC SYSTEM
It Yq 0 h l~~
Signature of Environmental Heal ecialist
Date
SEPTIC
4/08
1y 50/3511