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ETIM LAJk C.-p- Application # C v SC IM7 0 Harnett County Central Permitting PO Box 65 Lillington, NC 27546 CA 910-893-7525 Fax 910-893-2793 www.harnett.org/permits ~R'r> Application for Existing Septic Tank in a Mobile Home Park Applicant Name: Date: Address: Q C, Telephone: ~ ~ _ Property Owner: /o Phone:~~•_~~- Lot Address: "0'7' ~ Lot Number: Parc PIN: SW DW TW (Size _ZJ4 x?~J # Bedrooms ~ Year-_ Power Company: ~►J~ (For Progress Energy we need the premise number.) Name of Park: L - IW" . You signature below certifies that all above information is Signature of owner or authorized agent: CZ DO NOT SIGN BELOW - FOR OFFICE USE ONLY uthorization of Existing System ~s 0 Signature of Environmental He Specialist Date 1©32s SEPTIC 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.