ETApplication #
Pq ~17Y~7
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Applicant
Address:
Telephone
Property Owner:
Lot Address:
Name of Park: Lkl=5 m ( ~ V rn 14 P Lot Number: f 2~
Parcel:( -_i5 cm PIN:
X-Sw DW TW (Size -I~Lx-~JQ) # Bedrooms - Year 1qa3
Power Company: or Progress Energy we need the premise number.)
Specific Directions to job from Lillington:
CX) r7(~ql t-8B N
)b k-~'
If r
There Is a $100.00 charge for this service. This certification is subject to revocation If the
Intended use of the septic system cha as, or If false information is provided on this
application.
You signature be ow certifies t at all a e inform tion is correct.
Signature of owner or authorized agent: f en
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
\ on of Existing System
Signature of nvironmental Health Speci D to
a-3 l D 9
SEPTIC 4/08
Application for Existing Septic Tank In a Mobile Home Park