ETApplication #_._Lqls�'�A�
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(91 0) 893-7525 FAX: (9101) 893-2793 www,li<irtiett.org/l)ermits
C, &E_1:KA S EQN—\%,
APPLICATION FOR EXISTING SEPTIC SYSTEM4NSPECTION
FOR'MORTGA MMERCIAL CHANGE OF
OWNERSHIP 141RE DAMAGE ETC.
NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIM fOF A PPLICAVON.
vo._r&Nks
Date.
Proposed Buyer or Business, Narne:
Applicant/Mortgage Co:
Mailing Address:
City: __
Telephone:
State: Zip:
Other #: (
s Phone'l—J41
Current Land owner-
Property Address:
Parcel:
State Road #-_5p State Road Narne:_ECUX ��
Narne of Subdivision: —Lot # ... (If Applicable)
: # of employees__
int: # of employee
Directions: (please give concise,
# of children
Flours,
directions fr0ni Lillington, NC to the property)
`fihexe 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. 1
fi Z
.0
Your signattwe beloii' cei-ti fles thtit all abcwe infiffniation is corf-5��
Signature of Owner. AL►010rized Agent or Applicant:
FOR OFFICE USE ONLY
AU"I'HORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
of Envi - romnental Health Specialist Date
SEP,ric
4/08
0.
M