SEPTIC R Application # (✓ 5 ec 2 / 4'
,' ' Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910 - 893 -7525 Fax 910 - 893 -2793 www.harnett.org /permits
Application for Environmental Health Permit in Towns /Areas Zoned by Municipalities
d i'lr fr id-- Information: 4,1 o, 4zrnformation: 4 m ('94aw(P,s &I-wen/0 Name: Ali/ tik 4. ,,D ) li
Address: `Act fic-Aca,.J Likat Address: 99 "-cot", t. -r
him w e . 203 3 4 /li vn, 'vt 2833
Phone: \t0- t31- '-4 t Ue 3 Phone: /to - 244 -/023
Property Location: A /
E911 Address: ilia-,t /U/ [ /,,c1 / 44,,
PIN or Parcel Number: /5I6 - 0 7/ 99, ow / &Z /576 !too 0//
Subdivision: Nev , i f i % Lot Number:
Lot Size: 2 Zoning: Ahho Power Co: if(
Specific Directions to Job from Lillington: 1 421 -(v ANA) / f n/Gni if Sl /-
* TO /A; 2 3 (z,I.6nb < D0, -J,) -hap a / - /L5 /fj- div k 40,4
vD <toe:9 f- fern Ceirrikx? Y241 _Ca t 'e / 70_ cal 6Lup
Paive vp D1i-i v /v LAND 6A -ck.. mot)
Proposed Use: �7
(\) Single Family Dwelling (Size: ( x 0 ) # of Bedrooms:
Basement: Basement w/ Plumbing: Deck: Slab or Crawl Space
( ) Multi Family Dwelling # of Units: # of Bedrooms /Units:
() Manufactured Home (Size: x ) # of Bedrooms:
Garage: Deck:
() Business Square Footage Retail Space: Type:
() Industry Square Footage: Type: •
() Home Occupation # of Rooms: Use:
() Addition to Existing Building Size: Use:
() Other:
Water Supply: (t(ounty ( ) Well ( ) Other
Sewage: (New Septic Tank (Complete new tank checklist) ( ) Existing Septic Tank ( ) Sewer
There is a $250.00 charge for new tanks, $100 for existing tanks. This approval is subject to
revocation if the intended use of the septic system changes or if false information is
provided on this app ' n. Your s',gnature below certifies all information above is correct.
Applicant Signatura( Date: `1 -/3 - /o
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