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Application # 0q 500 (cR316)
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: ~v S ✓I Mme, Date: ` 17-
Address: 2.q iZ'CXe
Telephone: --M3 136 .5 ~S33y
Property Owner: Phone: C}l0 -0g 7- 72-7?-
Lot Address: 50 4
Name of Park: [ pv f- (a a
Parcel:-
-4-SW _ DW
Lot Number:
PIN:
TW (Size x# Bedrooms J Year-1171F4
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
You signature below certifies that all above information is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
7-5-05
nature of Environmental Health Specialist Date
SEPTIC
7///09A/
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.