ETCj (b Application #
IoSOo yp
HARNETT COUNTY CENTRAL PERMITTING SCAN:
PO BOX 65 LILLINGTON NC 27546 DATE
(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 OF APPLICATION.
Date: ,2 //1 /a2y l 4)
Pr posed Buyer or Business N
A licant/Mortgage Co:
Ma ing Address:
Te16h e (
Other
State:
Current Land Owner: Ph ne:_Y/O ?go -0o
Property Address: -¢I tk I r
=J P, ot ,2-771 1 4 4 )o
n
PIN: - Ds' . 0 arcel: 13 Ci q0 u
State Road State Road Name: ry 1-+ Q
C
714
Name of Subdivision: of # (If Applicable)
Daycare: of emp ees # of chi
rs:
ant: # of emplo of
Reseats Hours:
Directions: (please give concise, complete directions from Lillington, NC to the property)
n ~-o rzu--1 A- h q2 I tom{ s4 S
~ `t a-r5 ~f ~nn s t a 4.~,. ~c~ S 1~►Z.u Gco ra ~ % ~c-c ~ I
Tfiere 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 informatio is
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
4iaa ur e of Envi ntal Health Specialist - Date
SEPTIC
4/08