ETApplication # A 2 Z LOU
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX (910) 893-2793 www harnett org/perm>ts
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
Date ` Z ( - /2-
Proposed Buyer or Business Name
Applicant/Mortgage Co
Mailing Address
Citv
Telephone ( )
State
Other # ( )
Current Land Owner G L2a Y (,s )m /Ai
Property Address O. /a t <<i'r 4
PIN arcel
State Road # D State Road Name
Name of Subdivision
# of
of
Directions (please
# of
Zip
916 , 2 71- 1,07T
complete directions from Lillington NC to the property)
lr-o
Your signature below certifies that all above information is correct
°a lz .
Signature of Owner, Authorized Agent or Applicant ~-e^ k IAI 1~~~ 3 -21.
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
y- 3--f Z
Signature of Environmental Health Specialist Date
SEPTIC
4/08
fl:
Z
„ -yr
Lot (If Appheable)
)intended use of the septic system changes or if false information is provided on this
application