ETIf
Application # 612 l f
yl HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
kAjo ry ~ (910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSP
ECTION
, ETC
NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: x'
Applicant
Mailing Address:n ro i~Y~
City' State:
oe! (4x, Other ( }
~-c it Current Land Owner: /\)(kyln t i ()e-tn ^ ; c
PIN: ~i+4
State Road
Name of Subdivision:
vo Parcel:
State Road Name: I
/ -4
Zip:
:~g~~3 Qa13
° 4/
# G (if Applicable)
Directions: (please give concise, complete dir efct o n s from Lillington, NC to the property)
-raxp ry lr^ r, , \ n 8
Dt r
-'k or-
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 T
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signature nvironmental Health Specialist Date
SEPTIC g(~t~
4/08