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HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits
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NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRE AT TIME OF APPLICATION.
Date: - 1 gF-02
Proposed Buyer or Business Name:
Applicant/Mortgage
Maili d~dUss:
City: State:
Telephone: Zip'
` Other ( )
Current Land Own.
Property Address:
PIN;
Parcel:
State Road State Road Name:
Name of Subdivision: Wig- Lot #
(If Applicable)
Da~are: # of employees # of children Hours: _
Restaurant: # of employees # of seats Hours: -
ve cone, camp to directions fr Liliir ton, 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 inform ti is c rre
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING
gnature of Environmental Health Specialist
SYSTEM
/D-Z7,
Date