ETApplication # 6T / ~3Uz
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Date:
Name:
Addre;
Teleph
Property Owner:
Property Address Phone:
Name of Park:
Parcel: b Lot Number:
State Road Number: PIN'--~-~ -Z-_~j~Z ,Job
State Road Name:
-SSW DW TW (Size # Bedrooms Year
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:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signs re of Environ entai Health Specialist t. d '7. o
Date
10/06
Application for Existing Septic System Inspection for a Mohile Hmmn eft..