ETApplication #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Application for Existing Septic System Inspection for a Mobile Home Park
Date: ,
Applicant Name:
4-4
Address: _
Telephone: Ncl. VY,- 3v 3 l
Property Owner: Phone: Cj _ ~
Lot Address:
Name of Park: Lot Number: r15 1
Parc
PIN:
SW DW TW (Size t" x L~~) # Bedrooms Year Lco I
There is a $100.00 charge for
I D
service.
intended use of the septic system changes, or certification alseinformation is to
provided o on i this
application. n
You signature below certifies that all above infor ati n is
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FORdF_FICE USE ONLY
Authorization of Existing System
'~-.FYI ~ ~ ti~-•~-~
nature of Environmental Health Specialist Date
/o /VA/ 5,07
Specific Directions to Job from Lillinaton: