ETApplication # It 7-1/570 2 ? 4--2
HARNETT COUNTY CENTRAL PERMITTING
PO BOX 65 LILLINGTON NC 27546
(910) 893-7525 FAX (910) 893-2793 www harnett org/permits
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION
FOR
FIRE DAMAGE
NOTE A DEED OR OFFER TO PURCHASE IS REQUIRED AT TIME OF APPLICATION
Date 9 ` 7,1 - ! N
Business Name ~r + ~s S i Z> V"-Q. 1Vt6
Applican
Mailing Address
City State Zip
Telephone ( ) Other # ( }
Current Land Owner G/
Property Address a 2V ,S." - s l ll/ p 1--~
PIN L* 4 - G/ 0-o - Parcel t/ 0 b/ oc
State Road # 1~ -13 State Road Name Vel ys 6-
-r-Name of Subdivision - T t
n
rr
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 O LY
AUTHORIZATION FOR USE OF EXISTING SEPTIC SYSTEM
?411-/A -
l 2Z-2
gnature of Envir ental Health Specialist Date
SEPTIC 4/08
#f Anolicable)
t
Directions (please give concise, com&te directi~s fPT Lillington,~NC to the property)