ETApplication # O`t 5 0 0 2 O
Harnett County Central Permitting o C1 g 5 t -1
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: wF~' ~~nuRT1E~5 t' Date: 34O
Address: 1+1~~? S ~L.... A _ if
Telephone:
Property Owner: 91b a, 5 S Phone: 919 - `toy -"S
Lot Address: _clmwz •-Sjk a.war'~ L
Name of Park: to ~SnNTFS M WP Lot Number:
Parcel: _ PIN:
SW DW X TW (Size 2-Li _x `J ) # Bedrooms _ Year __LJ_
Power Company: a 4cj W (h" (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
You signature below certifies that all above i ation
Signature of owner or authorized agent:
NOT SIGN BELOW - FOR OFFICE USE ONLY
rization of Existing System
5 51 6
Signature of Environmenta Hea cialist ate
;:5-i k
SEPTIC
4/08
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.