ET06130J2011 09 57 #454 P 001!001
Application #
HARNETT COUNTY CENTRAL PERMIT'T'ING
PO BOX 65 LILLINGTON NC 27545
(910) 893-7525 FAX (910) 893-2793 www harnett org/pemuts
APPLICATION 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 30 " , o&
Proposed Buyer or Business Name
Applicant/Mortgage Co
Mailing Address
City State Zap
Telephone ( ) Other # ( )
Current Land Owner d- Ph
Property Address Z
PIN O 52J- ik!2 ..5'4 7 - o a b Parcel
State Road # State R ad Name G
Name of Subdivision AA J.61 i- Lot
of #
concise, complete directions
one
eetr 9th - %2V - (9 17
--L--(if Apphcabte)
)urs
NC to the vronertvl
There is a $100 00 charge for tlfis service This approval is subject to revocadon zf the
intended use of the septic system changes or if false information is provided on this
application
Your signature below cert4 fees that all above information is correct
Signature of Owner, Authorized Agent or Applicant
FOR OFFICE USE ONLY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
ZZ4111
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of Environmental Health Specialist Date
SEPTIC
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