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Application#
HARNETT COUNTY CENTRAL PERMITTING U
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX: (910) 893-2793 www.hamett.org/perm'ts DATE
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION fc-T
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NOTE: A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION.
Date: cl~L~i E i i
Proposed Buyer or Business Name: _ A'► Z L-ro ov C v T-Et2 P 2 .C 5 a" S , Div[.
ApplicantlMortgage Co: sre PHE ov Jn r I-TO N
Mailing Address: jots StAr^v, , f ,V 27 LLff i'Y1ON M AW i!C5 t2Q.
City: L; I •u State: nv c Zip: Z S y t,
Telephone: O t 3v 3. 1,94 -1 Other ( )
Current Land Owner: On •"►ta.v E~v4y,,p,--'seS , .'NC Phone: 4 +o. to 3. 1947
Property Address. 143o S- V L O 5`rAm AD-, 4-S'A,Colf A )C z. 757e t
PIN: c~e~92~ flr~ -7(c~+f+. oc _ Parcel: OtAo(ftI 66tS
State Road State Road Name: OL(3 51)kS . ,hA61
Name of Subdivision: R. C, {Snow A Lot # i- (if Appitcabie)
care: # of employees of children Hour :
Restaurant: # of a ours;
Directions: (please give concise, complete directions from Lillington, NC to the property)
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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: 771-J-""'-
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
of Environmental Health
-7-1 i
Date
E-Health Mortgage Application 1 of 1 08110
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