SEPTIC Application # /25 25 00
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.
NOTE: / A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: /✓ — / 7 10
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Applicant/Mortgage Co: M n10 .n dc. a" 4 .r .I d 14
Mailing Address: / 1$ 1) 2 tf at I d
City: Sig ,nr01d C.State: j1) C Zip: a
Telephone: (. 3S2.- c)/ 92.— Other #: ( )
Current Land Owner: ,BQ(X' // 14-kin S Phone:
Property Address: (
PIN: S — '2. — 25 OC Parcel: 0, 6' 0
State Road #: 2. 2 State Road Name: 4 4'
Name of Subdivision: Lot # (te Applicable)
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Directions: (please give concise, co plete directions from Lillington, NC to the property)
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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 is correct.
Signature of Owner, Authorized Agent or Applicant: :. J.
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signature of Environmental Health Specialist Date
SEPTIC 4/08
NAME: APPLICATION #: /0 572i 2 C - 4 07
This application to be filled out when applying fora septic system inspection.*
County Health Department Application for Imurovement Perini antt%r Authorization to Construct
IF THE INFORMATION IN THIS APPLICATION IS FALSIFIED, CHANGED, OR THE SITE IS ALTERED, THEN THE IMPROVEMENT
PERMIT OR AUTHORIZATION TO CONSTRUCT SHALL. BECOME INVALID. The permit is valid for either 60 months or without expiration
depending upon documentation submitted. (Complete site plan = 60 months; Complete plat = without expiration)
910 -893 -7525 option 1 CONFIRMATION # i (l ,5 /
❑ Environmental Health New Septic SystemCode 800
• All property Irons must be made visible. Place "pink property flags" on each corner iron of lot. All property
lines must be clearly flagged approximately every 50 feet between corners.
• Place "orange house corner flags" at each corner of the proposed structure. Also flag driveways, garages, decks,
out buildings, swimming pools, etc. Place flags per site plan developed at/for Central Permitting.
• Place orange Environmental Health card in location that is easily viewed from road to assist in locating property.
• If property is thickly wooded, Environmental Health requires that you clean out the undergrowth to allow the soil
evaluation to be performed. Inspectors should be able to walk freely around site. Do not grade property.
• All lots to be addressed within 10 business days after confirmation. $25.00 return trip fee may be Incurred
for failure to uncover outlet lid. mark house corners and property lines. etc. once lot confirmed ready.
• After preparing proposed site call the voice permitting system at 910- 893 -7525 option 1 to schedule and use code
800 (after selecting notification permit if multiple permits exist) for Environmental Health inspection. Please note
confirmation number (liven at end of recording for proof of request:
Use Click2Gov or IVR to verify results. Once approved, proceed to Central Permitting for permits.
Environmental Health Existing Tank Inspections Code 800
• Follow above instructions for placing flags and card on property.
• Prepare for inspection by removing soil over outlet end of tank as diagram indicates, and lift lid straight up (if
possible) and then close back down.(Unless inspection is for a septic tank in a mobile home park)
• After uncovering outlet end call the voice permitting system at 910- 893 -7525 option 1 & select notification permit if
multiple permits, then use code 800 for Environmental Health inspection. Please note confirmation number (liven
at end of recording for proof of request.
• Use Click2Gov or IVR to hear results. Once approved, proceed to Central Permitting for remaining permits.
SEPTIC
If applying for authorization to construct please indicate desired system type(s): can be ranked in order of preference, must choose one.
{_) Accepted (_) Innovative {_) Conventional 1_1 Any
(_) Alternative (_} Other
The applicant shall notify the local health department upon submittal of this application if any of the following apply to the property in
question. If the answer is "yes ", applicant MUST ATTACH SUPPORTING DOCUMENTATION:
{_ )YES {_} NO Does the site contain any Jurisdictional Wetlands?
(_)YES (_) NO Do you plan to have an iIDearion system now or in the future?
{_ }YES {_) NO Does or will the building contain any drains? Please explain.
(_)YES {_ No Are there any existing wells, springs. waterlines or Wastewater Systems on this property?
(_)YES {_} NO Is any wastewater going to be generated on the site other than domestic sewage?
{_)YES (_) NO Is the site subject to approval by any other Public Agency?
{_)YES {_) NO Are there any easements or Right of Ways on this property?
(_)YES {_} NO Does the site contain any existing water, cable, phone or underground electric lines?
If yes please call No Cuts at 800- 632 -4949 to locate the lines. This is a free service.
I Have Read This Application And Certify That The Information Provided Herein Is True, Complete And Correct. Authorized County And
State Officials Are Granted Right Of Entry To Conduct Necessary Inspections To Determine Compliance With Applicable Laws And Rules.
I Understand That I Am Solely Responsible For The Proper Identification And Labeling Of All Property Lines And Corners And Making
The Site Accessible So That A Complete Site Evaluation Can Be Performed.
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PROPERTY OWNERS OR OWNERS LEGAL REPRESENTATIVE SIGNATURE (REQUIRED) DATE
11/09
DIAGRAM OF- Ate A
a TLET LID
POSSIBLE POSSIBLE
HOUSE HOUSE
CONNECTION -- CONNECTION
POSSIBLE
HOUSE
CONNECTION
POSSIBLE LID SHAPES
1 - 1 SQUARE (SHOWN ON DIAGRAM)
j ij RECTANGLE (OLDER TANKS) - ROUND
MOBILE HOME RENTAL AGREEMENT
BY THIS AGREEMENT MADE AND ENTERED INTO ON 10 I S , 20 BETWEEN
x x',(l (4Acm� (LESSOR) AND than, -mo Q• J X((Y Y CdJ ES1SIE). LESSOR
LEASES THE PREMISES SITUATED AT ILA c '-\ Hends cs sd IN THE CITY OF SANFORD,
COUNTY OF HARNETT, STATE OF NORTH CAROLINA, AND MOR PARTICULARLY DESCRIBED AS
FOLLOWS:
FOR A TERM OF ONE YEAR TO COMMENCE ON t c,: c 5- 06 kb
1. RENT. LESSEE AGREES TO PAY WITHOUT DAMAND TO LESSOR AS RENT FOR THE DEMISED
PREMISES THE SUM OF $ c.t) PER MONTH IN ADVANCE OF THE 1 DAY OF EACH
CALENDAR MONTH BEGINNING ("r etC)21 .
2. FORM OF PAYMENT: CASH OR MONEY ORDER MADE PAYABLE TO BEVERLY ADAMS.
3. LATE PAYMENTS. FOR ANY RENT NOT PAID BY THE 5 DAY OF THE MONTH, THERE WILL BE A
$50.00 LATE FEE.
4. SECURITY DEPOSIT. ON EXECUTION OF THE LEASE, LESSOR DEPOSITS WITH LESSOR A SECURITY
DEPOSIT OF $ 3ct 00
5. QUIET ENJOYMENT. LESSEE SHALL PEACEFULLY AND QUIETLY HAVE, HOLD AND ENJOY DEMISED
PREMISES FOR THE AGREED TERM.
6. USE OF PREMISES. THE DEMISED PREMISES SHALL BE USED AND OCCUPIED BY LESSEE
EXCLUSIVELY AS A PRIVATE SINGLE FAMILY RESIDENCE.
7. NUMBER OF OCCUPANTS: LESSEE AGREES THAT THE DEMISED PROPERTY SHALL BE OCCUPIED
BY NO MORE THAN c2 PERSONS.
8. KEYS. LESSEE WILL BE GIVEN (2 KEYS.
9. PARKING. ANY PARKING THAT MAY BE PROVIDED I5 STRICTLY SELF -PARK AND 15 AT OWNER'S
RISK.
10. UTILITIES. LESSEE SHALL BE RESPONSIBLE FOR ALL UTILITY SERVICES REQUIRED ON PREMISES.
11. ALTERATIONS OR IMPROVEMETNS. LESSEE SHALL MAKE NO ALTERATIONS OR IMPROVEMENTS
TO THE PREMISES WITHOUT TH PRIOR WRITTEN CONSENT OF THE LESSOR.
12. DANGEROUS MATERIALS. LESSEE SHALL NOT KEEP OR HAVE ON THE LEASED PREMISES ANY
ARTICLE OF A DANGEROUS, INFLAMMABLE, OR EXPLOSIVE CHARACTER.
IN WITNESS WHEREOF, THE PARTIES HAVE EXECUTED THIS LEASE THE DAY AND YEAR FIRST
WRITTEN ABOVE.
LESSOR 1 ' �L 1 ! ! 14 I447 SEE 6C� R. Y ) r 4 t\00.,\ .Pt4/■
LESSOR �� LESSEE Y7rJiarcl.Lics-