ETr Application # I I S 00 R a3
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/pennits
OWNERSHIP, FIRE DAMAGE, ETC.
NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF
Date: I J 12Z /
Proposed Buyer or Business Name:
Applicant/Mortgage Co:
Mailing Address:
Citv:
Telephone: ( ) _
State:
Other k ( )
Zip:
Current Land Owner: ryPhone:_/'
Property Address: 2-!7 .7-- Co.,- t P?,'// /f 4(' C". c.tij
PIN: 1 ` { 3 1;-.5 , 000 Parcel: 1-56
State Road State Road Name; 3Z7~ Cc /7,
Name of Subdivision: Lot # _(If Applicable)
of e ployees # of children Hours:
# of alovcs _ # of
seats lctfs
Directions: (please give
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. 1.4
M~~ ~ 4
Signature of Owner, Authorized Agent or Applicant: d'4
41
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
ature of Environme tal Health Specialist Date
SEPTIC
4/08
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