ET1W R S y Y/
Application # 0 T6~1lr Z Z L-1 2-
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
A-$ R
FOR MORTGAGE COMPANIES,
NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: -
Proposed Buyer or Business Name: I~A-T s ~^I
Applicant/Mortgage Co: pup at<S t 1an►tc
Mailing -Address: 3 N' ST'
City: 1- m _ rM/+ State: d Zip: 2 75 2 G
Telephone: (414 669-A111 Other (io) - 06`b
Current Land Owner: Phone:
Property Address: 1174 C/ 1`S r AEA L= I,- cQ LAu ,P~1 Z'V i
PIN: 0 - oa Parcel: 417 ~ °
State Road Name: r
Name of Subdivisi t f Applicable)
ours
iDavcam-,: # f em ees of childregaft ,e%
e es s s VM660. 14W mp o
Directions: (please give concise, com fete directions from Lillington, NC to the property)
V 0 ) owAn.n< ANA axe ON SSA ~,Gi4-i pry /*t/t131
c r` LM~xd_ n,.1 1 <1,4 fltl . tro'iZNLa- LJr► _ 1_ l,Aif~r~~Ai ACJ_ 4-L•._J1S~
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 correct.
Signature of Owner, Authorized Agent or
SEPTIC
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
of Environmental Health Specialist
R^zg--o5
Date
VT 1,
0/19 109 At 4108
d ~,v /0 a