ETApplication #
4 WV/
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX (910) 893-2793 www harnett ora/nermits
NOTE A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION
Date Proposed Buyer or Business Name
Mailing Address ,~t'~tJL4~~
City State Zip
( )
Telephone ( ) Other #
Current Land Owner
PIN i1(o S ^ ~n Parcel 13 9G Z0 07 Z J 01
State Road # _ State Road Name
Name of Subdivision ~c 6/9 Lot _(If Applicable)
Directions (please, give,copcise, complete
NC to the
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
Dr., FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
Health Specialist Date
SEPTIC
4/08 5
03 2 2 -7 CC.)
7
ETC