ETApplication # _u 51% -21/
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Application for Existing Septic System Inspection for a Mobile Home Park
Date- 3
Narne-7--
Address:
Telephon
Property Owner: _ IA2140
Property Address:
Marne of Park: A
parcel:
Road Number:
State RoApn
SW DW __.,TW (Size
t
,�6 _Phone: ?1e)"
L.ot Number:
PIN:
State Read N � rT i e:
#Bedrooms Year,
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 infor ti correct.
Signature of owner or authorized agent., Z:Z
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
c
ign:a=re of Environme tal Health (7 -
alth Specialist Date
10106