ETApplication #-10- Soo - l`(71 o
HARNETT COUNTY CENTRAL PERMITTING
ID PO BOX 65 LILLINGTON 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 DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: 7-/--//-,2
Applican
Mailing Address: ~O 0" AD k
City: 6/1AUIZEf State: A/G Zip: 2~5~9
Telephone: Other V/O a
Current Land Owner: ,U G one:
ne:
Property Address:
PIN: D3! / Parcel:
State Road -Y State Road Name: S.~/ ?o.~ Gd . .~d,
Name of Subdivision: ce4 r;:~' Lot #
---2_([f Applicable)
Pa care: of a of ' dren
e p oye
t f of s Hours:
Directions: (please give concise, complete directions from Lillington, NC to theroperty)
There is a $100.00 charge for this service. This approval is subject to revocation if the ov lrl' it
intended use of the septic system changes or if false information is provided on this 0`7< 02 /
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
NIP 1111!~ C)
S ature of Environmental Health Specialist Date
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