ET22
Application #
v
CP
Harnett Count Central t 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: f 1 j j s rLs
I- i Date: S - ;2 -
Address:
Telephone:
C
Property Owner:
P4., k L R6w.att ~
.,ps C 1.1 1! G-s
Phone:
bra-`~~Y- ~3 SG q
Lot Address:
I
J Ef --,U
b 2
Name of Park: ( _11 I I f (OLot Number:
Parcel; 03- ~i -7? - 8/ PIN: 7- JT-- 76 o a
i SW DW TW (Size tx'7;D_) # Bedrooms Z Year t qg~
Power Company: Er- oLS(For Progress Energy we need the premise number.)
S ecific Directions to Job from Lillin on:
You signature below certifies that all abo
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
of Environm
I Health Specialist
s f~
Z11-
Date
,T/,27/of 5
WAR
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.