ETApplication 2 )-a> 2 D 4~P.
Harnett County Central Permitting
PO Box 65 Ldimgton, NC 27546
910-893-7525 Fax 910-893-2793
www harnett orglpermits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name '4-F C ' -Date 2-
Address I~ rn~ r n 94 a r ~,x ~'I r . 2? a
Telephone (04" - tty Y z - / b o a
ban v% W0*tr i~1 4 4 w-
Property Owner ,,~p p J- "T L L G Phone 91 y ~ ~b s
Lot Address a
Name of Park - Lot Number
Parcel PIN 1~ p" 6 yam, p~~/
SW DW TW (Size qx # Bedrooms Year 1
Company (For Progress Energy we need the premise number)
Specific Directions to Jobifrom Llllin ton
t. X-7 .
You signature below certifies that all above Infor tlon is correct
Signature of owner or authorized agent
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
4ign=ureof Environmental Health Specialist Date
SEPTIC 4108
-45
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