ETC1 - t -7120/0
Application
HARNETT COUNTY CENTRAL. PERMITTING
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. COMMERCIAL CHANGE OF
OWNERSHIP, FIRE DAMAGE, ETC.
NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OFAPPLICATION.
Date: 1,?, 0 q
Proposed Buyer or Business Name: 1`05 niq
Applicant/Mortgage Co:
Mailing AddresL n i' 7C
,7& c
State:
City: f-1 - GlI
Telephone: Other ( )
MA +2T 10- (qLC-X i s
lo R2TG A 6E
RUC Zip: a2 /
Current Land Owner: eO(Wo-ru Lt)-i h, I
Property Address: I o ~I IL 0 rl V-P-
PIN: U53c4 -lad- Dg-!W, L-4~ Parcel: 01 D
State Road aoH 5 State Road Name: i'1/1
Name of Subdivision: Fr - rA .n U , ~ ~,r~ L (C
Phone:91 Dill', c/ - 7
Lot # X13 ? (ff Applicable)
031'endl-
'S3 Co a
gp3g0
3f emP1 ees children
# of emu vees # of seats
Directions: (please give concise, complete directions from L
NC to the property)
51 a }n+-a S"-M c
There is a $100.00 charge for this servile. 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 ins correct.
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUT O ON FOR USE OF EXISTING SEPTIC SYSTEM
R~~~S ~ h t b
Signature of Environmental Heal pecialist ate
SEPTIC 3p/~jc-7 4/08