ETApplication #l l f Q ~CLâ–º-_l
H A.RNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION FOR
SINGLE FAMILY DWELLING
NOTE: WHEN APPL 'ING FOR AN EXISTING SEPTIC TANK INSPECTION FOR A MORTGAGE
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Date: P&a S e Cw'I It o4
Proposed%*:'y p
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Applicant/Mortgage Co:
Mailing Address: l ~Q- LN
City: ('CLAW jw State:
Telephone: (~j Fax:(
E-Mail:
Current Land Owner:
Property Address:
State Road Number:
PIN or Parcel:
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: r/v
FOR OFFICE USE ONLY
TION FOR USE OF EXISTING SEPTIC SYSTEM
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Zip:
GD~~~c Phone:
8/06
11147, (~7
Name of Subdivision: Lot # (if Applicable)