ETApplication #
Harnett County Central Permitting
PO Box 65 Liliington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Date:
Name:
Addre
Teleph
Property Owner:
Properly Address:
Name of Park: t
ke"-' lone: L 3q - 4. d
Lot Number:
PIN: a/ 93 - 9~ = 3 O 7 , v~p
S%e Road Number: State Road Name:
SW DW TW (Size x- ~(J) # Bedrooms _ Years
Snecific Directions to JQb fr^rn LRlinaton:
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.
You signature below certifies that all above information is correct.
Signature of owner or authorized agent: M.
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
of Environmental ~Heaft~hSpe~ciali s t Date
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014 ~ ,ate
Application for Existing Septic System Inspection for a Mnhilo Mnn,e o,...