ETApplication #Q~
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION FOR
MORTGAGE CO. FINANCING COMMERCIAL CHANGE OF OWNERSHIP
FIRE DAMAGE ETC.
IVUI E: A M E40 UR OF
FER TO PURCHASE IS REQUIRED AT TIME OF APPQ ATIUN
Date: 7
(t' hi- 0 W riuelrS
Proposed aw4w:
4
Applicant/Mortgage Co:
Mailing Address:
c''ty:
'
State:( Zip:
-
Telephone:
Fax: Z/, 5o
Current band Owner:
Phone: - -
Property Address:
-
PIN:
Parcel:
Name of Subdivision:
Lot # (trApplicable)
Daycare: # of employees
# of children Hours:
Directions: (please give concise, complete directions from Lillington, NC to the property)
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 Applicak./ vl A uâ–º1,4, o1 I"
FOR OFFICE USE ONLY
AUTH , &~ION FOR USE OF EXISTING SEPTIC SYSTEM
Signature of nvironmental He specialist Da
s
ldok
7,5V(e
8/07