ETVN-R<-V-C4V1Vj 11 : JJtt r muri: t.AlUIY 1 R 7 r ri.Lm rILA'CJ 7 1 I J I JJJ
11Jr Ji Jit-- ..J{-I-?- 1 .1
Application # _ d a~QJ
Harnett County Central Permitting
PO Box 65 Liflington, NC 27546
910-693-7525 Fax 910-893-2793
www.hamett.org/pormfts
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: ar d Date.
. 3 ~ Co v
Address:
Telephone: ___n I Ck - n.-_q D - L f l q
Property owner: Q~at' yt..~9~1} Q ~ ~ 1 Phone: Ck Q -7-7 Lot Address: Ci ("Yli C
Name of Park: YY1 Lot Number:
Parcel: PIN:
_ZSW DW TW (Sizex } # 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 Informatio is correct.
Signature of owner or authorized agent: L----
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
l Aut'horization of Existing System
Signature of Environmental Head Specialist ate
S
Power Company: (Far Progress Enemy we need the premise number.)