ETApplication #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Application for Existing Septic System Inspection for a Mobile Home Park
Date: -Lk~- 0 311 b-j
'
Name: N n 6 (-V- 7- V
o►
Address:
Telephone: °l 1 ,5 - V) `t - - A 55
Property Owner: )7N6 E9-Sa n/ 01444 h, kip Property Address: C,
Name of Park: n/ ern 0, 24 Lot Number:
State Road Number: State Road Name: Akr-k;`
You signature below certifies that all above info ation is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
±1
of Existing System
s a7
Date
Signature of Environ
Specialist
,Q~:t,o}~ home nod %-died..
Jul 9A
t~A~c~~ - ta9'1 01/1
S
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8,08
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.