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RARNM COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546 !`l DA(910) 893-7525 FAX: (910) 893-2793 www.hamett-orgipermi.ts
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTIt]l'd
FOR MORTGAGE COMPANIES, COMMERCIAL CHANGE OF
OWNERSHIP. FIRE DAMAGE. ETC.
NOT-. A DEED OR OF R TO PURCHASE TS REQUIRED AT TIME OF APPLICATION.
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Date: / -7
Proposed Buyer or Business Name: ~ C-* 9 < 01C' X=•A AD
ApplicanttMortgage Co:
Mailing Address: ;13 Q l +'u it A J!Zeol
City: 5 w.t cr State: tL,Gr pZip. ~ a
Telephone: t(f) q-4 w Other#: ) V21? --~.-3--5
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Current Land Owner iFrp.4~V 1 k'p 30rr. one:
Property Address: ?s f s`c, r`+t- " • <-,a . ,c l • a 7 3 3 0
PIN:415 rob -25-l o %q xoc> Parcel: C9i s -s O nLA
State Road State' Gd Name:
Name of Subdivision: Lot # {EfAppticabh~)
Da dare: # of crnployees # of children Hours:
Restaurant: # of employees.____,_ # of seats Hours:.
Directions: ((prIease give concise, complete directions from Lillington, NC to the property)
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AN9A /3,.eLt_sut.. P4r~n.,G /W;* 40% P,&AL2,lt 3mit~e.. `IA;~ MfV f) 6iL'1A,
There is a SlbO.40 c a for fWs service. This approval is subject to revocation it the ,U."M '"ye,(lo-cl
intended use of the septic system changes or if false information is provided on this p ~ ~Srd~ fikot
application. E,,,'tf S>✓ - hu ra c 1,
Your signature below certiftes that all above information is correct. ,-f --r- te 4-
Signature of Owner, Authorized Agent or Applicant: 4 al,44Lt2-t11 ~ -
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTI SYST
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Signature of Envlranrnenta7 Health Specialist )Date
&Heelth Mortgage App5cation i of 1 08/10
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