ETApplication # 0°t 5C ?kI8 59
Harnett County Central Permitting NED
PO Box 65 Lillington, NC 27546 3/09
910-893-7525 Fax 910-893-2793 DATE
www.harneft.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name:
ate: S-c- 5-01
Address: ~Z/ l GJrJt. ,A~ (-C~~ 12,J 7S'~
Telephone: - Sio 7- A~~Y -
Property Owner: 11~ir - t D-0-/V 41~ ~ rccor- L Phone:--'/ Lot Address: Af .,1.'A , s
lName of Park: ~j,(y0 ~Lot Number:
Parcel:-p-1 Nogg- ooeo PIN: oc, 9'2- `7 (0 -,A 8oE• oo c
SSW DW TW (Size xo ) # Bedrooms 3 Year 41
Power Company:: ALES ~c~s ~~rs~•~ _(For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
42 7 ,?5 / tome ` I/f~iV -r'C A( CA, 7, 1,5 J- rX ~
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.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
ig ure of Environm al Health Specialist Date
11,109
SEPTIC
4/08
Co►J r 1v $ 8 'Qi~ ~