ETApplication I ~1,LJ 2 2 Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic S stem Inspection In a Mobile Home Park
O~ /1/71 Applicant Name:
~r.-Qk- Date: J
Address:
Telephon(
Property Owner:
Lot Address:
Name of Park:
Parcel:W-
--SW -V DWTW (Size x
Power Company
hone:-'~'If7
_ Lot Number:
PIN: .--O ~ Noq - 61. (4)-A qL4
a # Bedrooms Year
it Progress Energy we need the premise number.)
You signature below certifies that all above infoAation is
Signature of owner or authorized agent:
- DO NOT SIGN BELOW - FOR OFFICE USE ONLY
thorization of Existing System
Signature of Environmental Health ecialist ate
Z/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.