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Application # 10-50-7-yt,S S
FI'ARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGT
ON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE COMPANIES COMMERCIAL CHANGE OF
OWNERSHIP FIRE DAMAGE ETC.
NOTE, A D ED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: Z1 l 4
Proposed Buyer or Business Name:
Applicant/~4esg
Mailing4ddress:
City: J-au 11 e- Telephone: ( PiT/ p-4
State: JY C Zip:
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Current Land Owner: 161t2ijA e A T~¢ L, r~ G t b r-1 Phone:
Property Address: 22 S m c1 3 6- 6 ,,J 6-s CV-41K 2 7 5- l~
PIN:_ 02521 --1-) -3536 ooo Parcel: 1) 023 ocr,1
State Road LA21 State Road Name:_ Ll°Lt 5v-rTt►-
Name of Subdivision: Lot # _(If Applicable)
Da care: # of employees # of children
Restaurant: # of employees # of seats
Hours:
Hours:
Directions: (please give concise, complete directions from Lillington, NC to the property)
C02-5 1 nlC 110Y 'AZl SwT►t Va-,)4 tSo -(,4.40
F2~r~ If~% y 2 7 t~l Tf~ SEcru-l
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:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
gnature of Environmental Health Specialist Date