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Application #
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Harnett County Central Permitting
PO Box 65 Ullington, NC 27546
910-893-7525 Fax 910-893-2793
www. h am ett. o rg/perm its
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name:
Jgffitj:S~in ~ W. 2J
Address: `7 - -
Telephone: Q )Q 7 ,
Property Owner:
Lot Address: _ P
Name of P
Lot Number: ?L4
Parcel: ~j rj (3 J ( PIN:
y
s-SW DW TW (Size .x~ # Bedrooms Year
Power Compan _
y~~-i -Progress Energy we need the premise number.)
~S
e ~f 3'070t are 'n t- '
onl
ere s a 4100.00 charge for this ce. 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 tion is correct.
Signature of owner or authorized agent:
SIGN BELOW - FOR OFFICE USE ONLY
~ Authorizz
Signature of Environmental
()~7z
of Existing System
5 k o~
Specialist Date
S
4108