ETApplication #
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HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
3 (910) 893-7525 FAX: (910) 893-2793
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION FOR
SINGLE FAMILY DWELLING
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NOTE: WHEN APPLYING FOR AN EXISTING SEPTIC TANK INSPECTION FOR A MORTGA E
/ COMPANY`, A DEED OR OFFER TO PURCHASE WILL BE REQUIRED
Date: 1Ub (-QQS e C~zf d ostYt " &)r1 h Ol-~u
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Proposed Buyer: n f i h r, Yl,- I ( C1l ()9q n 111 nQ 60n
Applicant/Mortgage Co:
Mailing Address: $5 a
City:
Telephone: (Q* $ V ~
E-Mail: M,"1 1V L1, -J
Current Land Owner:
Property Address:
State Road Number:
QkOt-1819 -Qa57
Name of Subdivision: QrC1 j~KP I~ Lot (if Applicable)
Directions: (please give co
PI 0 sse, complete directions from 111n on, NC to the property)
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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.
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Your signature below certifies that all above info is correct.
Signature of Owner, Authorized Agent or Applicant. M(&'
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signat re of Environmental Health Specialist Date
a/,2 7/0,y 8/06
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7 -40 WOL-S d do 4-h-i's
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State: M C Zip: ~ ! r »'t ►n u`~~
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