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Application
02/01/2013 10:17 #351 P.0021002
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits
NOTE: A DEED OR OFFER TO PURCHASE I5 REQUIRED AT TIME OF APPLICATION.
Date: �L - 1- e3 o..t 3
Proposed Buyer or Business Naxne: A 2-1 t-d r U
Applicant/MortgageCo: U-56A
Mailing Address:. Ji6 t 1-44t
City: —t f W i A State: C- Zip: 0-9 33S
Telephone. Rio) ti -561-4 to Other #.- (ci to)
Current Land Owner: . H a ±Ja&nLA - tnc ) "x A _.Phone:-,-
Property Address: CL r C- Iq
�r-,A PIN: 0-11--'siz 00q3 117 P=el:Po
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State Road #: State Road Name:
Name of Subdivision: De—ac t C-C�r-M Lot Applicable)
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of
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 information is correct.
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
N
ignature of Environmental Health Specialist
SEPTIC
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Date
4/08