ETApplication # Oct 5 c t 9 q
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793 3c NED
www.harnett.org/permits 09
Application for Existing Septic Tank in a Mobile Home Park DATE
Applicant Name: 4Date_ I
Address: Q 616 n
Telephone: Q to
Property Owner: k ~1) r1
Phone:
~L~~7- 3 ~ 3
Lot Address: q~ C , San i~ t X(
Name of Park: ak)`~h~rnp Ci '~J M Lot Number: q(Q
Parcel: PIN.
L-,SW DW TW (Size _Lq_x -7o ) # Bedrooms
Year ►9 06, t.
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
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:
ds;v
NOT SIGN BELOW - FOR OFFICE USE ONLY
rization of Existing System
Signature of Environmental
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ate
41 q /Cl
SEPTIC ^ Q~ ~~t (o
Q'-1 ~r~~z r 4/08