ETApplication # 0 7 7
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: 6 Z y
Applicant Name: G
Address: V 71 C
Telephone: -7LI .t -7- 44 /r
Property Owner: ,?c li Phone:
Lot Address: 7`,
At &7-143 - 01 L Al
Name of Park: 54,,, Lot Number: j~,~
TP e l: 07 % k no- 2 01 PIN:-1-4o f7 1V&
14719 SW DW TW (Size x# Bedrooms ---7- Year
.C• O' .
00 e
a
Specific Directions to Job from Lillington:
You signature below certifies that all above information is correct.
N
Signature of owner or authorized agent: 0,6,e v~
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
uthorization of Existing System
gnatu a of Eawdonmentil Health Specialist Date
5/07
I IItylV 10 A * IVV.vv W.JQlya IV$ tl110 `.f l-........ v....)..... •v .v.vvv~w~~ so %11%p
intended use of the septic system changes, or If false Information is provided on this
application.