ET RApplicatfoll
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/perrilits
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CATION FOR EXISTING SEPTIC SYSTEM INSPECTION
OWNERSHIP, WE ETC.
NOTE: A DEED OR OFFER TO PURCHASE ISREQI,'IRL,'I)ATTIWI,-'OFAI,'I-'IICATION.
Date:
Proposed Buyer or Business Nagle t
drew 0 t d
Nlailill" I
,
City: State L
'27
Telephone:
4 Other EL
Current Laud Owner : b IV A( 0 /Q Pholle:
Property zkddress'.
P I N: Parcel:
State Road #: State Road Narue:
Narrie ot'Subdivision: Applicable) of scats Restaurant: A of employees 4
Directioris: (please give con�i,,sctorri e L fiLL ii,s from i in fly)
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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 signalure bclow certifit, Y that all above hifinwicnioll is correct.
Siouature of0wrier, Authorized Agerit oi- Applicalit-`��_
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FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
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Signature of Environnfental Health Specialist Date �
SEPTIC 4/08