ETIL
Application #
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: Date: Z - 2 Q f
Address:
Telephone: 61 cl
Property Owner: 7C' 1lLa Phone: 5 °l f
1 fi
Lot Address: 74
Name of Park: a v IKwl e 4-~r-d`Q Lot Number:
Parcel• 4- -7 PIN:
_ylSW DW TW (Size # Bedrooms - Year
Power Company: (Far Progress Energy we need the premise number.)
Sgecific Directions to Jab from Liltinaton:
There Is a $140.00 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 infor tion is correct.
Signature of owner or authorized agent: fIX
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of
Health Specialist
ate
SEPTIC 4/08
;2
C~~3~..`