ET-1!
r Application Saa ~a
L l Signature of Owner, Authorized Agent or Applicant: LT
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE COMPANIES, COMMERCIAL CHANGE OF
OWNERSHIP, FIRE DAMAGE, ETC.
NOTE: A PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: ;7
Proposed Bu er or Business Name: ,~GL
Applicant/Mortgage Co:
Mailing Address:
City: . - A cJ State: Zip: e2s -?,I?
Telephone: (P/p) A" 9-W3 7 Other ( )
Current Land Owner:
Property Address:
PIN: C7S?9-
State Road t~ O a T State Road Name: L 2-r-S S'C'1 H v-k
Name of Subdivision: - Lot # (If Applicable)
# of
Directions* (please give concise, co to directions from Lillingto . IBC to, th property) ~J -5
e
5~ r? 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
D r application.
Your signature below certifies that all above information is correct.
C
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/permits
of
# of children
Hours:
of Environmental Health
3 z-1l
Date
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
A /AA
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