ETApplication # -10 Soo d q-) (J j
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION FOR
SINGLE.-FAMILY, MOBILE HOMES DAYCARES MORTGAGE CO.
ADDITIONS ALTERATIONS COMMERCIAL JOBS AND ETC.
NOTE: A DEED OR OFFER TO PURCHASE IS REOUIRED AT TIME OF
APPLICATION.
Date: / ~j .1~~~
Proposed Buyer: /"OE;~
Applicant/Mortgage Co: --1~~
Mailing Add[2ss: a?
City: State: zip:
Telephone: Fax: ( )
Current Land Owner. one:
~974V 09
Property Address: _~J~-,~
State Road Number: PIN or Parcel:
Name of Subdivision . i Off rj:~ /VJ _Lot # (irAprncanle)
a car payees Hours:
Directions: (please Uive~ncise, cpmplete directions1rom LPlington, NC to the
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
Signature of Environmental Health Specialist
Date