ETI, `741
Application # 1 1_500 HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX (910) 893-2793 www harnett org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE COMPANIES, COMMERCIAL CHANGE OF
OWNERSHIP, FIRE DAMAGE, ETC
NOTE A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION
2 - vw~cmu 0La«
1-d-,425-242-34 Other # (
~o Current Land Owner
Property Address
PIN t )I_n_ -q
State Road # q L tu.~ra•~__ -State Road Name
Name of Subdivision Lot # (If Applicable)
Daycare # of employees # of children Hours
Restaurant # of employees # of seats Hours
Buyer or Business Name
(please give_concise, 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 is correct
Signature of Owner, Authorized Agent or Applicant iY rte-
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signature of En i nmental Health Special
II-q-11
Date
SEPTIC 4/08
Date UJ3 k