ET RHTE# ,5~--~'I)31~Z--LO HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE # & '7.) - 7 ? }
ADDRESS C: 11,E L,/ Y_1 N V11)) N L
NAME OF MOBILE HOME PARK OR S/D Urc Xi-c( Z4. li'f Z
NAME OF OWNER (IFDIFFEREN7) % 1(//,, ~~c Ian 1- 4-
ADDRESS OF OWNER (IFDIFFEREN7)
PROPERTY LOCATION: STATE ROAD NAME AND # ✓y
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THIS INSPECTION IS VOID IF:
(1) the intended use of the septic system should change, and/or
(2) the system should fail or malfunction, and/or
(3) the owner or tenant of the property changes, and/or
(4) after six months
BUILDING MU81 BE FROgA Y PART. OF SEPTIC SYYSTEM
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. 00 NO bRIV6 Oq ?AR 01[ SEPTIC SYSTEMS U",
CHORIZATION OF EXISTING SYSTEM
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3igna Environmental Health, Specialist
Date
Initial Application Qate: Application M
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CWQA OF HARNE7T RESIDENTIAL LANG USE APPLICATION CU
Central Permitting _ 108 E. Front Street, Liitingt/o'n, NC 275" L Phone: (910) 893-7525 Fax: (910) 893-2793 /r!I/ www.harnett.org
LANDOWNER: Meng Address: ~f2 Ti,.~c Jam/
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City: 0~tir yr State. Zip: LI 3 Home N: Contact N:
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APPLICANT': {6~/ttJ ' t.
L' G ti Marling Address:. V Gty Stats:v Zip: Home N "Contac~' 7 l_l Y
*r' ease h' ut aopl,cant.nforrnation d different than landowner
CONTACT NAME APPLYING IN OFFICE: LPN L /e Phone
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PROPERTY LOCATION: Subdivision: t S T Lot M: Lot Size:
State Road 4: -__-slate Road Name: Map BookBPage:
Parcel: 5 y PIN: L72 ✓9 ~t-0
Zoning: l ~r5 Flood Zone: Watershed y ' 11 # d BookBPage:
SPECIFIC DIRECTIONS TO THE PROPERTY FROM LILLINGTON:
opnPOSEO USE. (Include Bonus room as a bedroom it It has a closet) - 14:
SFD (Siz-__ _x_ p Bedroomr N Baths_ _ Basement (w/wo bath) Garage Deli lab
(Size _xk Bedrooms s Baths Basement (wAvo bath) Garage Site Built Deck ON Frame I OFF
Manufactured Homo: _SW 4~DW _TW (Size x N Bedrooms 3 Garage ~(slle bulk? Dedc_,~
(olts txdk9~~
J Duplex No. Buildings No. BedroomeNnd
J Home Occupation K Rooms Use Hours of Operation: #Employeeo
J AddlttoNAccessorylOther (Size_x__ ) Use Closets in addition(jyes (ono
Water Supply: (Lef"C"unty U Well (No. dwetlingo ._J MUST have operable water before final
Sewage Supply: L) New Septic Tank (ComplaM Allow Tank Chec"S4 (,,r}6stktg Septic Tank County Sewer
Property owner of this Iract of land own land that contains anufact home win five hundrgd low jSoo-) of tract Noted above? OYES
Structures (existing or proposed): Single family dweNngs AAartuf Haines L~ Z er (specify)
nta:
Required Resldentlal Property Line Setbacks:
7
Fronl Minimum Actual
Pear
C'osest Side
SjuestroeVcorner lot
Nearest Building
cr same lot
permits are granted 1 agree to conform to all ordinances and to" of the State of North Carolina regulating such work and the specifications of plans submitted.
I nereby state thatloregotng statem is are accurate and correct to the hest of my knowledge. Permit sub)ect to revocation if false information is provided.
Signatbr! of Owner or Owner's Agent Date
"This application explrea 6 months from the InMal date if no permits have been Issued-
A RECORDED SURVEY MAP, RECORDED DEED (OR OFFER TO PURCHAM AND PLAT ARE REQUIRED WHEN APPLYING FOR LAND USE APPLICATION
Please use Blue or Blade Ink ONLY
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SITE PLAN APPROVAL
DISTRICT USE
#BEDROOMS
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