ETApplication #15 ( C
HARNETT COUNTY CENTRAL PERMITTING
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 6
NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: S` tri ` S
P r m
usess ame:
Applicant/mmtgagr£'ti: "
Mailing Address:
City:
Telephone: (qIJ —Is 1,
Current Land Owner: Phone:
4 Pro erty Address:
e LJ
State Road #: State Road Name: `
Name of Subdivision: Lot # - 0f Applicable)
Directions: (please iye concise, com#te directions from L�ll}ngton, NC to the property)
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 i c rrect.
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY 1-11
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
g13 /5-
S ature of Environmental Health Specialist Date
SEPTIC
4/08
is