ETD9 I Application # 0~ 1560 00'~
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnen.org/permits
Application for Existing Septic System Inspection in a Mobile Home Park
Applicant Name: 7~os Date: d- / a. I o9
Address: _SCn E. 1 x i t w+s C- Anna i P~ N G 5 n t
Telephone: a to( - (,o tat
Property Owner: '-So vyle✓ Phone:
Lot Address:
Name of Park
Parcel:
PIN:
_SW DW TW (Size 14 _x=?O) # Bedrooms -S_ Year lot~i4
Power Company: 'Prb,j j ,ss 1 _(For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
2 1 C~ N /t +f`- a ~n-t &%A f?~easzt L-,"r Sn
rnn
Nn~~- l~o~sc tv~ 10; nAovrv. f new 1^~~c e7 o4 an S;~
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
ignature of Environmental Health Specialist Date
41 ~ 3101
N V08