ETApplication # ~ TP ZZ 3g~7
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 Tank in a Mobile Home Park
Applicant Name: ! C~fyL GAS-p2 Date: 6-30-0
Address: t~ Z F-oU-bt-- rt-2/11 MJC71_C t/ Al' /-fit 1_pI rt kv,
Telephone: q Z 0 42 0 , rZ/ `
Property Owner:
Lot Address: L} C /'1/~ }4r(,1LJ ,
Name of Park:_ t()___~ 1, I~IV Lot Number:
Parcel: PIN:
SSW DW TW (Size _ x_7_[~ _j # Bedrooms ;7-Year- 2-000
Power Company:_ Agl1 je_4Q (For Progress Energy we need the premise number.)
St)ecific Directions to Job from Lillinaton:
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 information is co ecf:
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System _~17 ? c. F"O,... 'e- j-
0 ?
Signature of E onmental Health Specialist Date
3c~~~9s
SEPTIC
4106