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ETApplication # 11 500 -Z(o 1 $ 0 HARNETT COUNTY CENTRAL PERMITTING PO BOX 65 LILLINGTON NC 27546 (910) 893-7525 FAX: (910) 893-2793 www.harnett.org/permits ETC_. NOTE: Date: OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION. Mailing Address: City: Telephone: (qc) Wbe'aLl Current Land Owner: Property Address: CPS X1:2 PIN: b559i-IB-90o State Road 9.01 cl Name of Subdivision: State: Other k ( ) Zip: SCAW*- D WE G -80- 4 )lease 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 correct. Signature of Owner, Authorized Agent or Applicant: FOR OFFICE USE ONLY TION FOR USE OF EXISTING SEPTIC SYSTEM of Environmental health Specialist D to U'L-L-( i ,-31►S1,(I y ooo Parcel: ►o0 55q d© 52 State Road Name: y o cpL11+. M_c. vlev! t-► Jr, Lot # -(If Applicable)