ET4 Application # [ L-500 q
HARNETT COUNTY CEN'T'RAL PERMITTING
PO BOX 65 LILLINGTON NC 27545
(910) 893-7525 FAX: (910) 893-2793 www.harnett.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- 2a1C
Proposed Buyer or Busint
Applicant/Mortgage Co: _
Mailing Address: 7
City: $ 4 DWI
Telephone: 0/f '770
Current Land Owner:
Property Address:
PIN: oSa7_ 0 3 - 2 3
State Road 11
Flame of Subdivision:
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:ss Name: - y
State: A,1 c.- Zip: Z-7-33E
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.000
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Parcel:
Road Name. 1&174 ~ s ¢
Sfi E r r s ,t 3 Lot # Z? (If Applicable)
llaycare: # of employees 11 # of children Hours:
Restaurant. # of employees- # of seats Hours-.
Directions: (please give concise, complete direr ions from Lillington, NC to the property)
Q- 12 ,~rrt.,f J -r- L 00C rs /Z_ fob (/N,rr.~'
K+Aa 27 wof s,' R
40 1, -
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 inforntativn is cor
Signature of Owner, Authorized Agent or Applicant:
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signature of Environmental Health Specialist
SEPTIC
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Date
4 ~ f ~ / I C
4/08
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