ETLxa,s t_ (t0 qqA kS ~ Application # f a 500 a73i 9
HA TT COUNTY CENTRAL PERMITTING
PO BOX 65 LII.LINGTON NC 27546
Lq rN - 90 (910) 893-7525 FAX: (910) 893-2793 www.harnett.orglpermits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: % - l S- a 9
Proposed Buyer or Business Name: Ufa ~'~S $ o c~~i,~~ tAt~ 11~ C
Applicant/Mortgage Co:
t z9
Mailing Address- `Fc ' --9 C> ,4
City: /`L! k-r-> " State: IBC. Zip: of "754 G
Telephone: tG '-"S 19 - Other ( )
(please give concise, corn fete directions from Lillington, NC to the property)
a c- aA/V aid si~*&. r oed
There is a $1100.00 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: 4~7
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signature of vironmental Health Sped ' t Date
SEPTIC
' 11 00 4108
Ai
Current Land Owner. Ua V Y\\ J kS e-O S 1C H _Phone:
Property Address: 162's 'old- '54-aar i'd- or.,-As &Y---
PIN: p681-83-84+g4.oaa Parcel: O 7o6&1 oaj?
State Road I 001.p State Road Name: o s la se-Ld
a
Name of Subdivision: Lot # (If Applicable)