ETApplication #
NOTE A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION J `
Date 3--20 ~ 2014 b
5
Mailing A
City `
Telephone
Current. Land Owner J u I o zalw wml ri ll Phnne
7S 7
Property Address C' c vU5 h 1tT //r '0-6 9 PIN 00 Parc J
State Road # State Road Name g r
Name of Subdivision 602:~6'4'0 Lot # f (If Applicable)
favsare I of wolouses #.af cbAdren Hris
(please give concise, complete directions from Llllington, NC to the property)
SdHA A /I T4 !q-15 ottfti / cx f -'4 t75n~S6oYu KG
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
4 .r
Signature of Owner, Authorized Agent or Applicant 4,W It-ti ,P1 i diA
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
o~
of Environmental Health Specialist
3°Z'i'fZ
Date
SEPTIC 4 4/08
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