ETApplication # o q Soo a 3 s i
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 SCANNE
910-893-7525 Fax 910-893-2793 a
www.harnett.org/permits DATE/
Application for Existing Septic stem Inspection in a Mobile Home Park
Applicant Name: nA Date: /or -2e-&J
Address: 5.272- Dal SP2",z S X04 ~r ~2 7 S~ s
Telephone: W__ Property Owner: 3+m / )C-r."CpL Phone: Z/?F_ lk
Lot Address: 7) (fit aP 0+ _
Name of Park: k 1) 6 rrt S
Lot Number: 7
Parcel: 0q 95fou 014c> 0S PIN: G5 Cn1-ct~ ~aoSS,yoC~
L--'SW DW TW (Size l _x 7(O } # Bedrooms _ Year /fi~r
Power Company: (For Progress Energy we need the premise number.)
S ecific Directions to Job from Lillin ton:
A 8 o~► ts_ T ~ a cl
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 inforAidiion is
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Envi
Health Specialist
5-1 00\
ate
ro/ag/mgs
Q6106
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