ET (electrical reconnection)Application # 4~
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910).893-7525 FAX: (910) 893-2793 www.hamett.or.Joerm
NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: ez~"4'~.e EL,,,
Proposed Buyer or Business Name:
Applicant/Mortgage Co:
Mailing Address:
City:
Telephone: ( )
State:
Other ( )
Current Land Owner: -Z Qr
Property Address: I a
PIN: Parcel:
State Road State Road Name
Name of Subdivision:
Zip:
# (If Applicable)
Daycare: # of employees # of children Hours:
Restaurant: # of employees # of seats Hours:
Directions: (please give conci a com lete directions from Lilli in, NC to the pr perty d
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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: -LVV ~
FOR OFFICE USE &1LY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
1A ~ " / e ~ r! 0/ 0
-Z'Ll '?Signature o nvironmental Health Specialist Date
SEPTIC rr /
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