ETApplication # 09 S oo ZZ t::~- I
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 SC NED
910-893-7525 Fax 910-893-2793 J 10 p
www.harnett.org/permits DATE
Application for Existing Septic Tank In a Mobile Home Park
~ ~1 I I I
Applicant Name: 1
11 5 m~ h m c Date: Ju~ _ o) 00
Address: _10 -7 r r1 t.ya~! y C ; h-~ C a2 7~ 6
Telephone: 3, - $ - 7,3 $i}
Property Owner: 4- 1~ a,r,c .,5~ 11'Phone: 3 3 G - 8 8S- 93_~d
Lot Address: I a 5 r) d t.r so r e
Name of Park: _BJa c I~.vc r R Lk „ Lot Number: ~Q h a WN Je*-
Parcel: 0*0624, Q PIN: 6&74'Zlfl -S~ 9000
SW DW TW (Sizex 7a) # Bedrooms 3 Year kW
Power Company: ,D ~ r SS ~nera (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinat n:
You signature below certifies that all above information is correct.
Signature of owner or authorized agent: c.
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
f'r/8-OS
ignature of Environmental Health Specialist Date
g//ol0y
SEPTIC
P-1111--d gl„lOy
4108
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.