ETAPPLICATION 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 a~
ran M
Proposed Buyer do091111INN N11111111
Applican
Mailing Address
City A~=f State Zip
Telephone t°►t1i Other # ( )
Current Land Owner G 1 ~..'C V C~ Phone C1 o ek 3 q'~
Property Address C%
O O 2 0
PIN U 4-17'" 2 9 71, O" Parcel
State Road # tate oad Name /A 1~,Alf
Name of Subdivision _ e, al /..g Lot # (If Applicable)
tar f emplo s f c re rs
eo to s f s
Directions (please e concise complete directions from Lillmgton, NC to the property)
_1 11T I- L~ a" n- Pv-
J
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
FOR OFFICE USE ONLY
A FOR USE OF EXISTING SEPTIC SYSTEM
WAS ~ Ua Signature of En ironmental Health Sp ahst e