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Application # `f
v HARNETT COUNTY CENTRAL PERMITTING
~J PO BOX 65 LILLINGTON NC 275
~r 46
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits
TION
FOR
• , FIRE DAMAGE, ETC.
NOTE: A DEED OR OFFER TO PURCHASE IS F APPLICATION.
Date: /9 - /I -
Applican
Mailing Ad e
NQJ
City: State: I la.- Zip: z J j 2~
Telephone: f~b _ Other { )
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Current Land Owner: Phode: K-~ 6:7'? ) 0 )i 1, -i, A) 11 ?
Property Address:
PIN:.q S' - 2 - 1135; aC10 _ Parcel: / 00 "
State Road 1 tate Road Name:
Name of Subdivision: Lot # (If Applicable)
Directions: (please give concise, complete
Lillington, NC ty the property)
There Js '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 Appli
FOR OFFICE USE O
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signature of Environ ental Health Special' Date
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