ETApplication # ( O 5 CC) -23
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793 7IDD
www.harnett.org/permits \ !NE
JDATE
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: ~
I Date: / ~ vl
Address: -5
- a /L'C
Telephone:
Property Owner: ~ct m e &,.)e J
Lot Address: Phone: 2
I n
jip.11111!1~~d Le AC ' ,4
Name of Park:, red
Lot Number:
Parcel:
✓SW PIN:
DW TW (Size # Bedrooms 2
Power Company: "m~ i i Year
(For Progress Energy we need the premise number,)
on 6e~i~e~ .yAfJis f C~ .~aJ^~
There is a $100.00 charge for this service, This certification is subject to revocation
Intended use of the septic system changes, or if false Information Is provided If the
application.
on this
You signature below certifies that all above inf ation is correct.
Signature of owner or authorized agent: AZZI
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
nature of nviro e al ealth Specialist
Date
SEPTIC,
114C/ //0
15
4/08