ETApplication#_ 5001"I M71
HARNETT COUNTY CENTRAL PERMITTING cm*D
PO BOX 65 LILLINGTON NC 27546 c - r
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/permits - ATC•
t
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR MORTGAGE COMPANIES,
NOTE; A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: ) -y6-1 I
Proposed Buyer or Bush
Applicant/Mortg age: Co:
City: _'2
Telephone:
Current Land Owner: _ ~r'4-A 6 Phone:
Property Address:
PIN: ~SS~z- (005`7, 000 Parcel: _t zresS 0001
State-Road State Road Name:
Name of Subdivision: ALbtxT rA or4 i Lot # z,4 f zu (tf Applicable)
Daycare: # of employees # of children
Restaurant: # of employees # of seats -
give concise,
2.{
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 in, formation is correct.
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
~ . . s , C.~~ 5f l 9 I
Signature of Environ ntal ealth Specialist Date
Hours:
Hours:
E-Health Mortgage Application 1 of 1 08110