ETa3 Application # d q 566 9 3_/),9
Harnett County Central Permitting
PO Box 65 Ul{ington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: _k lzo wr» ago& Date: /9 Qc D9
Address: Z WD Ae,. a-17 :15-AIJF DCO iC/e.. Z ~
Telephone: /
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Property Owner: tT "iY O,r Phone: A~? ~ .5'1,00
Lot Address: Q21~ dae. 0-*MAW !e ~g PA2 1~
Name of Park: ,z= )1)67 Lot Number: /9
parcel:_ nq CJ576 b J KS lC> PIN: !25-7g -W3 " W (Vq •600
R V SW DW TW (Size x# Bedrooms LYear 0_
Power Company: &4:W S7n&&E i5j42?aY {For Progress Energy we need the premise number.)
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Them 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 Lion is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
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Signature o vironmental Health Specialist Date
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SEPTIC
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