ETNOTI
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Application
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 2754b\\
(910) 893 -7525 FAX: (910) 893 -2793 www.harnett.6rg/permits
Applicant/ "a e` '
Mailing Address: 3'TS o --,tA_� lQ
City: tom. State: N\ Zip:
Telephone: ) R I `T - Other #: ( )
give concise, complete directions from Lillington, NC to
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Applicable)
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 infonnat on is correct.
Signature of Owner, Authorized Agent or Applicant: _
FOR OFFICE USE ONLY
TION FOR USE OF EXISTING SEPTIC SYSTEM