ETApplication #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permfts
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name:
C
q t7 A14, ~'S
l
Address: "6
Telephone: 919-
Property Owner: VAR9 A f'-l R~ 1dA-5 Phone:
Lot Address: .1)'6 r V X19 Name of Park: Lot Number: _
Parcel: 61 PIN: d 73
SW DW TW (Size l x__ Yi 1~1 # Bedrooms Year I q 14
Power Company: (For Progress Energy we need the premise number.)
t?d Aug 1 ~8
There is a $100.00 charge for this service. Thls 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 correct.
Signature of owner or authorized agent: CDaza 191 62~
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
' ignature of Environmental Health Specialist Date
SEPTIC
4/08