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DATc Application # 10 `S 00 -7A 4 5 to
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits
NOTE. A ttDEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date:
Proposed Buyer or Business Name:
Applicant/Mortgage Co: e
Mailing A ss:
City: t_y-3fk P_ ~ State: Zip~
Telephone: Other (Wb y 9 /
Current Land Owner: 61,50 1)(A c ~0-r Phone: / _ 4?%
Propert Address: P_ ► h G
PIN: 8, 91, 0010 Parcel: (n 3e5'Pt (D 1 S3 13
State Road b 12 11 q1 State Road Name: i e
Name of Subdivision: 144-?, igc d Lot # (If Applicable) P1fd,
Daycare: # of employees HOULS!
Restaurant: # of employees
Directions: (please give concise, complete dire tions from Lil in 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 information is correct. ba r.s ! sapzf-rjj0-~76y-4 ~
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Signature of Owner, Authoriz d Agent or Applicant: V'_ r7
FOR OFFICE USE ONLY
A RIZ TION FOR USE OF EXISTING SEPTIC SYSTEM
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Signature of Environmental a th Specialist to
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