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ET7-e- Vm- - e- c Application# V1-5CO-ZW'i( i NED HARNETT COUNTY CENTRAL PERMITTING tS PO BOX 65 LILLiNGTON NC 27546 DATE (910)1893-7525 FAX.: (910) 893-2793 www.hamett.org/permits APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION FOR MORTGAGE COMPANIES COMMERCIAL CHANGE OF OWNERSHIP, FIRE DAMAGE, ETC. NOTE. A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION. Date: _1-110 f 11 Proposed Buyer or Business Name: Applicant/Mortgage Co: Mailing Address: City: State:_C~ Zip: Telephone: (917 2 S - 2 Other ( ) l / 3 Current Land Owner: Phone: Property Address: C/ice c"~ nQ r.~ PIN: ©totS-Bt=1too , oo ts) Parcel: osotnt5 Qt8 ml State Road State Road Name: Name of Subdivision: Nx YG- 0M T&-,,c0 Lot # (If Applicable) Daycare: # of employees # of children Restaurant: # of employees # of seats - Hours: Hours: Directions: 1please give concise, Complete directions from Lillington, NC to the property) 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 Signature of Owner, Authorized Agent or Applicant: FOR OFFICE USE ONLY AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM - /oL /ow c~ J-Z-2,- & igna ure o ironm ntal ealth Specialist Date ~ ,.1~ C-C'r U