ETApplication #
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/pemiits
NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: /0 - /Z -
ApplicanUI / f
Mailing Address: 1-7 ' V L a
City: r-", -Q State:
Telephone: ( ) q! 0 - £r 1 Y -2-715 Other ( )
. t Zip: 02 -7 5 Z I
Current Land Owner: t Y t Cr.J 5 v. Phone:1 t J - W! Y - -7
Property Address: S vs rc C vi., a
PIN: g - 4 - 6 7, 0-40Y Parcel: 07 S B/
State Road State Road Name: ✓c?s <
Name of Subdivision: Lot # (if Applicable)
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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 Zco ;c G Signature of Owner, Authorized Agent or Applicant: FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
S n re of Envi onm I ealth Specialist Date
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Directions: (leasegive concise, ~cJomplete directions from L*11in ton NC toe propperty)
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