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15:40:13 i2-W2007
J"OM34793 Nwrad Couty PW"v KMt ETf CO. PLANMM SEW49XS ~s: ~
Haman County Central POrn'd&V
PO Boot 65 Liington, NC 27546
Telephone Number 910403-7525
Fox 91040134M
Septic System inspection for a Mobile Horne Park
A~~~~atldn~
Date:
Appikarrit t+lams: zoi
0 12f ~Nez h4W-1 42,Z "WA-7 ;V,7, Address:
Telephone: fa -9 ~2ef - -
^A b-. t -VV 1A 60 Property Owner: g~
lot Address:
Name of
par04 ~O PIN: p&
Iri -o _ 000
Parvel: SW pW TW (Size xd Bedrooms Year
There is a $100A0 charge fbr this swAm This m No -Uorr is subject 110 rwocatioe N the
intended use of dw septic system chages, or it false kdbrndbn is pnwMed on this
applia ftM
You signat<rre below certifies that all above' is correct.
Signature of owner or authorized agent
DO NOT SKM BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
deo&17S 1-:Z-68
rgneture of Envirorww tal Health Sped st Date