ET~l ag
l l /
U~ Appllcatton # Ql ~tP)
(q 5 q0
HARNETT COUNTY CEN'T'RAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION FOR
MORTGAGE CO. FINANCING COMMERCIAL CHANGE OF OWNERSHIP
FIRE DAMAGE ETC
NOTE. A DEED OR OPEER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION
Date: e?-//- 0 F
Proposed Buyer:
Ap licant/Mortgage Co: (ern Co ce o44
/YJ,4,p t Cam, t L
Mailing Address: a717 btrf u, go (1,
City: 0 44KkA4n+ State: Zip:
't'elephone: 0(9 5E9'3 - D to 0 8 Fax: ( ) _
Current Land Owner:
Property Address:
PIN:
Name of Subdivision:
Parcel:
Daycare: # of employees # of children
Directions (please give concise, complete directions from Lilli
flours:
;ton NC to the property)
C~Z/v -VIA I J4 %Z 17
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: ~~~~L11l~
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signature of Environmental Health Specialist
Phonc: l9- qq e -0&& e
Lot # (If Applicable)
Date
V)
m
8/07