ETApplication # P 64,1) 1a/ / / 7j
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Date:
Applic<
Addre:
Teleph
Property Owner: Phone:_ Si/,o 8'9 7 7,v
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Lot Address:
Name of Park:
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Lot Number:
Par el: PIN:
V SW DW TW (Size x / # Bedrooms Year
Specific Directions to Job from Lill ton:
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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: / sr DO NOT SIGN BELOW - FOR OFFICE USE ONLY
uthorization of Existing System
C_Z - /2 - ~_7
gnature Avironmental Health Specialist
! Date
5/07
'Y
Application for Existing Septic System Inspection for a Mobile Home Park