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05/02/2014 15:09 #037 P.001 /001
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE COMPANIES, COMMERCIAL CHANGE OF
OWNERSHIP, FIRE DAMAGE, ETC.
NOTE. A DEED) OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: � /f
T
Proposed Buyer or Business Name: ,5Pj-i 6 Foa,y 44-rla d c , rm G.
Applicant/Mortgage Co:
Mailing Address: P-0. A a X 100
City: ok l yi 4 State: W- Zip:
Telephone: (9r4y) Other t ( )
Current Land Owner: 0 LF tNGt2G -.b E 1 16 kk Phone:
Property Address: 3 ,W.2-7 ciqHrem
PIN: QQ ,?q 01q& Parcel: #J. � L7
State Road #: State Road Name: 2-
Restaurant: # of employees o2 # of seats —5 Hours: --'M- a G
`J0
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
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
JK S 20l
Signature o nvironmental Health Specialist Date
SEPTIC
4/08
A-