ETHARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546 f ORJ
(910) 893 -7525. FAX: (910) 893 -2793 www.harnett.org/permits, d a
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APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE' COMP& �CIAL CHANGE OF
NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRPDAT TIME OF APPLICATION.
Date:��
Proposed Buyer or Business Name:
Applicant/Mortgage Co: « 5 5�;P t f- (a
Mailing Address: Ve a !Z
City: L f- I [ State:
Telephone: qq) 1! - -2 Other #: ( )
Current Land Owner: tl ow"k m1 T -'_ _ Ph
Property Address: 3 5
PIN :tom_` _ Ste, '3�4'-A . Marcel CO
State Road #: State Road Name: of -5t"*ZS=
Name of Subdivision: Lot #,
# of en
it: # of
Directions: (please give concise, corn
/L> t 5' 7- C
Zip: 7.7 SOk5
*tBX.dren Hours:
# of se s _ _ Hours :,
N
s from Lillington, NC to the property)
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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
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE 014LY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
A-/ 4 /- / 1'r, rle R
Si ture of Enviro ntaf Health Specialist ate
SEPTIC 4108
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