ETApplication #
12- ~ ao 443
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 Tank in a Mobile Home Park
Applicant Name n6 N~ Oct., 11y Date 'ZOf z
Address g 6L40 b 1 S> Q5 L{ 2\ 1 (bA
Telephone 1 C6 g q 1Z F t
Property Owner Cl n's w "f l n,,,r Fr,,\L ?0,-)er3 Phone (1/6 ) ;~~d -02 2,z-
Lot Address (pZ Lo-'-~V r~, /L.rdce 6-d" a
Name of Park M Lot Number aS
Parcel{ ~ PIN
✓ SW DW TW (Size x 7 # Bedrooms - Year ftS-
Power Company ~~"pClcSS (For Progress Energy we need the premise number)
Specific Directions to Job from Lillington
t e,~~" ~t'1~ r nct ]
~:GLh'" 6" L a ti ✓ S-r
L
1t ~t s.'r' car. RL-C 1, There is a $100 00 charge for this service This certification is subject to revocation if the
intended use of the septic system changes, or if false information is provided on this
application
You signature below certifies that all above information is corr 't
Signature of owner or authorized agent l
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
thorization of Existing System
Signature of Environmental Healt~ Specialist ate
SEPTIC ~ l Z I ~to (o ~ ~ ~ 4/08
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