ETApplication #
27
9Z~
NOTE A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION
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Date ! 2 ► F
Applicant/
Mailing Address
City State C Zip
Teleph e ( ) / Other # ( ) /,P "7^ Y~ ri
Directions (please give concise, complete directions from Lillington, NC to the property)
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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 informati is cor ct
Signature of Owner, Authorized Agent or Applicant
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
1Z/--'t+5
of Environmental Health Specialist
Date
SEPTIC
4/08