ET-- 'I, -3 0 C1 l
( J, 3 Application # 1 C, ) -A
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Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Applicant
Address:
Telephone
Application for Existing Septic Tank in a Mobile Home Park
W.
Property Owner: 4-La&z-'4
Phone: 9
9- d:� �Z 2
Lot Address: C4 q-
Z 4-
Name of Park:
l /4/,ryw_ 421,
Lot Number:
Parcel: ..0 :L/ e
'0 416
PIN: ()U(J1q--
U-9- (-Hr'4"e)a)
0r'SW n T DW
TW (Size 42....-x
# Bedrooms _57�.
Year
Power Company: C1 C e— Clai,-, (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinglon:
5-i-gy"k, 44-
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 information is correct.
Signature of owner or authorized agent: , K., LL" 3�
SEPTIC
Authorization of Existing System
�r, 3
"A-,AVbJ T -) aLs ojlo �/g 11
Y.iiniture of Environkental Health Specialist Date
d 41�11
4/08