ETAp ication
~O HARNETT COUNTVCNTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
a S (910) 893-7525 FAX: (910) 893-2793 60r~ .W l L~ 3 -70
APPLICATION FOR EXISTING SEPTIC SYSTEM
q, INSPECTION FOR
SINGLE FAMILY DWELLING
D
NOTE: WHEN APPLYING FOR AN EXISTING SEPTIC TANK INSPECTION FOR A MORTGAGE
COMPANY. "D ED OR OFFER TO PURCHASE WILL BE FOLm? On
Date: .3-v, 7
Proposed Buyer:
Applicant/Mortgage Co:
Mailing Address:
Wiry: State: Zip.
)
Telephone: ( ) Fax:(
E-Mail.
Current Land Owner:
Property Address:
State Road Number:
PIN or Parcel: d- -
'F9~J- (7o n
Name of Subdivision: c.~tr~ ,~°.,fy~r
G (If Applicable)
Directions: (please give concise, complete~ections from Lillington, NC to the property)
00 A
a aluu.uu charge for this service. This approval is subject to revocation if the
use of the septic system changes or if false information is provided on this
Yourpignature below certifies that all above information is correct.
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
TION FOR USE OF EXISTING SEPTIC SYSTEM
'S
Signature of Environmental th Specialist Date
/o/s/ 8/06