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2'Z2 1 O ppZE Application # 10- 5Cn-Zy 01>14 HARNETT COUNTY CENTRAL PERMITTING PO BOX 65 LILLINGTON NC 27546 (910) 893-7525 FAX: (910) 893-2793 www,hamett.org/permits srkc r NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION. Date: .0 - v7o? -gA 0116 Applicant/hto;4p 0a-Co: Mailing,Address:531{53 k 5 City: Telephone: 1 °2q- ),,I State: `,2Z C_ dip: Other *4 3138 35 Current Land Owner: Phone: Property Address: - 33 PIN: o5~8'IS- tll~•ooc7 cel: o1©S96 co to State Road t1 State Road Name: E.4-w1A C%4ygAL V-q" Name of Subdivision: - Lot # - (if Applicable) Daycare: # of employees # of children Hours: _ Restaurant: # of employees # of seats Hours: Directions: (please give concise, complete directions from Lillington, NC to the 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 correct. Signature of Owner, Authorized Agent or Applicant: . 7 FOR OFFICE USE ONLY AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM Lure of Environmental Health Specialist Date 31,)3110