ET`eApplicat' n
Applicant Nam : ..2~2a ~
Address:
Telephone:. - ;
Property Owner:
Lot Address:'
Application #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
VJ
r xIsting Septic Tank in a Mobile Home Park
Date
Phone:
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Name of Park:
f.. Lot Number:
Parcel PIN: i✓,` `r7 1114 - 1~ 14r~)
SW DW TW (Size t_' x i ) # Bedrooms Year 1 ` t
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
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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 info ation 's correct.
X /J
Signature of owner or authorized agent: /m DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
ature of Environme al ealth Specialist Date
SEPTIC 4108