ET'J 1 } C, A6 Application # _ C)
SoC~ 3
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www. harnett, org/permits
Application for Existing Septic System Inspection in a Mobile Home Park
Applicant Name:
Address: Date:
Telephone:
Property Owner:
Lot Address: Phone:
Name of Park:
Lot Nu er:
Par7sw~DW el: PIN:
TW (Size '7U
---_x--LY--) # Bedrooms ---~5~ Year
Power Company_S ~ ~~e
(Far Progress Energy we need the premise number.)
LLB" ~r^~•-~^"~/
There is a $100.00 charge for this service. Z/6&/
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Intended use of the septic system changes, or if rti Is faleti Information (to revocation if the
application. Is provided on this
You signature below certifies that all above information
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Si ature of Environme I ealth Specialist
Date
-313a7~1
S