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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
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1 2 +o ti
DATE
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name:
Address: ,5 Date: /
Telephone:
Property Owner: '_34kM, e o e
Lot Address: p rf Phone:
f ,p J lj~
Name of Park: 5 f 4j
Lot Number:
Parcel:
- bW pw PIN:
TIN (Size /Y X
Power # Bedrooms Year
Company:
Wr (For Progress Ener
S 9Y we new the premiss number.)
D@Clf_i~ Directions o ~~h from r. Lillin
1
/ ~p
7"74 ,,6
iCar
There is a $100.00 charge for this service. This certification Is subject t revocation
Intended use of the septic system changes, or If false informatiIs If the
application. Provided on this
You signature below certifies that all above inf
tion is correct,
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
4a'ture o f Environ tai Health Spec1 st J~•-
Da
e
e
SEPTIC
Application # 10 -5, 0 O -236 8
4/08,