ETApplication # ~r_xc 2Z 1 (a
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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 System Inspection in a Mobile Home Park
Applicant Name: A #1n Irfi'c+ f Date: P;2- o
Address: ,5~272 &e SPP %w) Pic 6rof y ~75i15-
Telephone: Y. f 7 `ft'7-
Property Owner: J44rW%"1 JC11 G~r Phone:
Lot Address:
Name of Park: ' Lot Number:
Parcel: 00 0569- 04P) L--3Q- PIN: 1_1L (_q
SW _DW TW (Size . x(,cO') # Bedrooms Year
Power Company: 11 'v j, i -~,r aT, ,,,(For Progress Energy we need the premise number.)
Sgecific to Job from Lillin t n.
49
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4/4 ^ 4R r m "lfort wek r~
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 infoMition is
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
thorization of Existing System
'gnatur~/of environmental Heal cialist to
2/08