ETLin a C t; '@ A c
i
Application G 5-PO 27 7/ 7
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546 C' h~~ r^
(910) 893-7525 FAX (910) 893-2793 www harnett org/permits rJ ~1
NOTE A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION
Date f v 2 D `1
Proposed Buyer or Business Name'-
Applican lii"
Mailing Address io 6 3 6 l y s y z. t
City '4eP .vq P2w State N Zip
Telephone (9r 4 `6 e K ` 6 -lob Other # ( )
Current Land Owner S mA`/`` Phone
Property Address S i9 m 5 'Le
PIN /7L 10 .00 Parcel A Ll IZ/ -2 al
State Road # " 01 State Road Name
Name of Subdivision t f Applicable)
Restaurant # of employees # of seats Hours
D ~~ions ~~/le se gi a co vise, complete directions from Lillington 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 information i c rrect
Signature of Owner, Authorized Agent or Applicant
FOR OFFICE USE ONLY
d FOR USE OF EXISTING SEPTIC SYSTEM
. ~ Cb\L) WI
Signature of Environme`tlr c>Iahst a
SEPTIC 4108