ETApplication # 2Z 7Y7
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Date:
Name:
Addre:
Teleph
Property Owner: _
Property Address:
Name of Park: _
Parcel:-Q,
Road
VSW Numb
DW
I' Phone:
L44 Al %
,96* Lot Number:
a ap~ PIN:
r: State Road Name:
TW (Size xX) # Bedrooms T_ 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.
Specific Directions to Job from Lillin ton.
%00 -Id-
1 M
A
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You signature below certifies that all above info ation is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
~a a
1- J, 9
re nvironmental Health Specialist Date
)V--- rzz Z_: 3
`'~S X09
10/08
Application for Existing Septic System Inspection for a Mobile Home Park