ETt7N y, / C o'Q 111J 71a Application d l
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546 Aud Le- C
(910) 893-7525 FAX: (910) 893-2793
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPE0yTI6N FOR
MORTGAGE CO. FINANCING COMMERCIAL CHANGE OF OWNERSHIP
FIRE DAMAGE ETC.
NOTE: A DEED OR OFFER TO PURCHASE IS REOUIRED AT TIME OF APPLICAT70N
Dale: a6 ^/'w v~GY/
Proposed Buyer:
Applicant/Mong,
Mailing Address:
CiIy:. -A^V2
Telephone: W)
lzA
Current Land Owner: FMI0.4 Phone:
Properly Address: 'X I °I SAU~/d~115 ~l/yr T - q
PIN: 0S_PZy
056~zs3 , rl~v Parcel: /~R{~ q 3~f5 D/ DS Zy
Name of Subdivision: ET/i- 6,g S I of # (if Applicable)
Daycare: # of employees # of children Hours:
Directions: (please give concise, complete directions from l_.illington, NC to the property)
Q~i±?T C f/la.~•y 57- ate, 7-4-7N L e elti UsSio/ ,S~s /3F~r~
404 T t!L -2 / O
~tl ei/ .a y Al
9 S~ii uort~ cT -
"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 cc
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
FOR USE OF EXISTING SEPTIC SYSTEM
Signature of Environmental Hea
3a a
ate
8/07
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