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Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
for Existing Septic Tank in a Mobile Home Park
Applicant Name: lJ -T 0A l nf-
Address:
Telephone: 3!;3 Q31 q
Property Owner: Lv-ywe-
Lot Address: )91 iivP
Date: t `c9-7-V 1
Phone: s4vrj'~)'
Name of Park: Tire Jai ► ii yK H V Lot Number: ~ a
Parcel: PIN: _
A~ DW TW (Size x__IQ) # Bedrooms Year Power Company: (For Progress Energy we need the premise number.)
There- I$ 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 infor ation s correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
gnature of Envlronme al Health Specialist Date
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Application # O l '500 Q Q 6i~-S
SEPTIC 4/08