ETApplication # C,~( S (o c, p I O
0 97 1
Harnett County Central Permitting S
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www. harnett. org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: Ff<v ® o RTtE~ r~r„~.,,,« Date: ~4 3t
Address: i-l AQ
Telephone:
Property Owner:
Lot Address: ~ ~ ~ Phone: ~ 19 - 7p~ _ 575
Name of Park: _ L1 ptgA 14 s * c M 1} A Lot Number:
Parcel:
PIN:
SW -._DW TIN (Size Z x~ C~
Power Compan # Bedrooms
y: _-3_ Year inn (For Progress Energy we need the premise number.)
S e ific Directions to Job from Lillinoton:
T
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 thi
application. s
You signature below certifies that all above
Signature of owner or authorized agent
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
I~
of Existing System
Signature of Environm
SEPTIC
QJ
Specialist
Date
s!i lU9
S
4/08