ETENV 7) C ~ ~ X09
Application # 01 Son XJ q
Harnett County Central Permitting
SC ED PO Box 65 Lillington, NC 27546
1 1-:5 0 910-893-7525 Fax 910-893-2793
www.hamett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: 7 teW o l~ Date: Z
Address: Z'1 J_ -?e C/ .e /0 kwl
Telephone: V - mi'l` 5"yg '
Property Owner: V &4 Phone: q V9' s 10
Lot Address: 44- 7 Q~ ~v w N like o c/
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tl' SW DW TW (Size-1q x J ) # Bedrooms 3 Year lye' ~
Power Company: _ e- (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington: / r
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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 information is correct.
~~Z Signa
ture of owner or authorized agent: DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
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Signature of Env ronmental Health Specialist Date
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SEPTIC 4/08
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