ETHARNETT COUNTY CENTRAL PERM ITTING
PO BOX 65 LILLINGTON NC 27545
(910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits
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NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLI TION.
Date: -Z
Proposed Buyer
Mailing Ac
City:
Telephone:
Current Land Owner:
Property Address:
PIN: ~ Z9 - -
State Road jJL
-171
Name of Subdivision:
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60y
State:
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_ State Road Name: 13r:e f,
Zip:
# (If Applicable)
(please give concise, complete directions from Lillington,_NC to the
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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.
Yoursignature below certifies that all above information is correct.
Signature of Owner, Authorized Agent or Applicant:{.-
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
ture of Environmental Health Specialist Date
SEPTIC 4
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4/08