ETHARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX (910) 893-2793 www harnett org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR
FIRE DAMAGE,
NOTE A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION
Date -5-- Z5-)
Applican > -Ale- kl
Mailing Address So 11"05#9V LW
City 5 a ,icb L L., Ire State rt_J C Zip a B 3 R y
Telephone' 4 32- - ?q l R Other # ( ) 08- d i - 18 3'7
Current Land Owner W e. ~ - ^i • 6 Do, c, ( Phone '709-26L 1 E 37
Property Address b
PIN / -
State Road #
Name of Subdivision _
ns "50)- 19 L -t r<
0 Parcel 0 -5 3
# S. (If Applicable}
Directions (please give concise, complete directions fromillington, NC to the property)
7-eki e Flo f-o jek,,, Pecj -Imtre Gip fly
QtJ I.7a r"~ac1
h a t ct v L'/0 S fu II-e 6 5-t" MJ ke
:TA K< t 5+ - An to j!ino50,/ - rnd In v c.• r oh
There is a $ harge 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
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Signature of Envir'onm tai Health Specialist Date
SEPTIC it- j 4108