ETApplication # j j , j CJ 217 (4
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/pennits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE. COMPANIES FRCIAL CHANGE OF
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NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: 1-- a -A t \
Buyer or Business Name:
Applicant/M-6-ffgR
Mailing Address:
City:
Current Land Owner: 0,\,Zn KC Phone:- q I C)~SQ
Property Address: r-r- w,:Y, n; r 3 I
PIN: _j'1 z~ " S~ - 4~y a. c oy Parcel: n j C"
-1 CSI l
State Road Qj(5-1 State Road Name:
Name of Subdivision: Lot # - (if Anniicabie)
'ere is a $100.09 for this service. This approval is subject to revocation if the
! ended 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:
J
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
ature of Environ tal Health Specialist Date
c (ct ~l
1(
Other
Directions: (please give concise, complete directions from Lillington, NC to the property)
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C-A v\ r,\ AV E