ETApplication
Telephone: ( '-f eil-� 1j1-*1-'/ 11I)e-30 Other #: (
Current band Owner: �AAj A-) , 'f e Phone:
Property Address: CA qcv9 r
PIN:
Pq 2 27 Parcel:
State Road #: O(V
State Road Name:
Name of Subdivision:
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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 beloiv certijies that all above in imnation is correct--,
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
&ironme4notaleaiih S Date
Signa ure of Environmental Ith Specialist
SEPTIC, 4/08
ex,