ETOct 30 2012 9:11RM HP LASERJET FAX
1 0/30/2012 08;80 FAX UNC SAMFORD
-c� ✓ ;--
Applicatlor
Applicant Name: ,
Address:
Telephone: 9 [r
X041
Application #_I l , tC� f2-
Harnett County Central Permitting
PO Box 65 iJHington, NO 27546
910.893 -7525 Fax 810. 893 -2783
www.hamett.org /parmits
fnr i.vl&Nnn Can! {n lr&nk In s Uftlwnl Uw--
Property Owner: III, Phone: TI 4J�K 7
Lot Address:
Name of Park: o Lot Number:`,
Parcel: PIN:
.4-sw OW TVt/ (Sias r x_� # Bedrooms . Year_M A
power company,' ((WAM rl (For Progress Energy we need the premise number.)
'fire Is a $100.00 charge for this service. This certification is subject to revocation If the
lhtended use of the septic system changes or if fafse information is provided on this
opplicstion.
You signature below certifies that all above 1pqrmation Is c r ct.
Signature of owner or authorized agent:
WPM
v
DO NOT SIGN BELOW— FOR OFFICE USE ONLY
/�L' thorization of Existing System
illc X-1-1
ignatu a of Env ronmental Health Specialist . Date
ec d l0f -3/11
409
P.2