ETHAMETT CCOUNTY T DF-PARnWNT
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ENMONhOiTAL TH SE 91
307 C RNMIU T"T BLVD,
= GTO 9 NC 27546
APPLICAT10 OF EXISTING SEPTIC SYSTEM INSPECTION
A OIIII,19 ROME PARK
]DATE AZ/Z-5411
TELEFHONE(-2&~~- ~QS-~~-
-
ADD SS (ant)
MOBILE HONIE PAX
PROPERTY OWNER
K NAW TN /bP 6 OC~F,,ILZ/Y7i~~ 2 In
lnonhv Pr/~f'
PROPERTY ADDRESS
STATE RD NO, LOT NO,
D CTIONS (p ire CO, coa diwdiuM
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Pr V
There Is a S&W charge for ibis rvict. This atiflead n is subject to revocation if the
Intended u of the septic system char , or It &he Je a n is provided on this
spPlAcation.
Your si. natu below walffie4 that RD S vv 15TO OdOR h co.r d4
sip'liratun of O'ATs G>~~
7199
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-4759
MOBILE HOME PARK
Date:
Name: Z:Je ~
Address:
Mailing Address:
Property Owner:
Property Address.
State Road Number:
Name of Mobile Home Park:
Directions (please,give c9nci
ctiks)
oc-5-moo
zs. cc
~3 9v
LS8 13
1(_3 2 A (f X8390
There is a,$25.00 charge for s rvice. This certifica n is subject to revocation if the
intended use of the septic sy m changes, or if false info ation is provided on this
application.
Your signature below c ifies that all above information is co ct.
Signature of owner o Authorized Agent:
Do NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
06/02