ETApplication # z ~7~ 6
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-4759
Date:
Name:
Addre:
Teleph
Property Owner: _
Property Address:
Name of Park: _A
State Road N mbe
41r 4 ~Y_ OG
s
Lot Number:
b fmm 1 illinntnn• 7~- Z6
h frn
- Take HWY 210 N to Angier. At the intersecion of HWY SS turn left. Go about two mites. Tam left
onto Rawls g lurch Go about 3 miles, Black River Run Wl? in on the left. Lot l,is the first tot
-on 10
There is a $25.00 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: L
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
12-15--08
nature of nvironmental Health Specialist Date
9/D8
W
08104
Application for Existing Septic System Inspection for a Mobile Home Park