ETApplication## 11-500-2G 01 `l
HARNETT COUNTY CENTRAL PERMITTING lCi
PO BOX 65 LILLINGTON NC 27546 -Z
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits OAT" -
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION tryst-
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NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: .2 - V- - J/
Proposed Buyer or Business Name:
Applicant/Mortgage Co: ' y, ; s , rnn rl-ono -
Mailing Address: ! lr rrti 's Lcxn2.
City: -4 co ; - State: C. Zip, -2 75 d i
Telephone: ( ) I 1 ,7 - 8 fia Other (9r) J. 5 t --72 T i
Current Land Owner:-5o,-,d,- g S f e n n so 3 Phone: 1. 5/ 9 - q p 9?
Property Address: /p ~m Lore Any Nom'. T-50 t C- 9/ 4 -.x.73.-173 a
PIN: pC~$2~ Co(a-(cCo2Cc ,oor> Parcel: t7~-totoS3 02.5 D
State Road 1532 State Road Name: OAK- Grto if G+vvf.,-t+ Ro
Name of Subdivision: ,e z.P jJ5 FAH & Lot # 1 (if Applicable)
Daycare: # of employees_
Restaurant: # of employees
# of children Hours:
# of seats Hours:
g c A Jn 1: n k i'na f, 4- 4 f s C~ r, ~ r
There is a $100.00 clrge for this service. This approval is subject to' revocation if the hc'zr.7 s d e-
intended use of the septic system changes or if false information is provided on this O 4 fie- r pad
application.
Your signature below certifies that all above information is correct.
Signature of Owner, Authorized Agent or Appli~. ^°j
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
ature of Environmental Health Snecialist Date
Directions: (please give concise, complete directions from Lillington, NC to the property)