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250 Application # Z S~
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/Permits
APPLICATION FOR EXISTING SEPTIC SYSTEM jfNiPr ON
Mt _141 C L L d .-a GT
NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Applican .
Mailing ddre :
City:
State:
Other ( )
Gip:
Current Land Owner: Phone:
Property Address.
PIN - Parcel:
State oad k State Road Name:
Name of Subdivision: Lot # (If Applicable)
Daycare:. #
seats
Your signature below certifies that all above information_jy correct.
Signature of Owner, Authorized Agent or
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
z -/0
gnature of Environmental Health Specialist Date
i~
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.