ETApplication # Z~ u 4
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits
IN
FOR
NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: 0(p Z cqa I ~20J Q
Applicant/Mortgage Co: Pic tkz r to f A. L_a-A--- -
Mailing Address:
City: OW11 ] State: A/C- Zip:
Telephone: Gk)) f SR - 006S'+ Other (ql(J
Current Land Owner: MA
PIN: - - Parcei: 6,2 /4- o
State Road /9 OfL State Road Name: LO/JG IfJ
Name of Subdivision: n/4 Lot #-(If Applicable)
6 ,0~ 74
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 Applicant:
OWNERSHIP, FIRE DAMAGE, ETC.
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM.
6 25 -1 D
re of Environmental Health Specialist Date