ETApplication # 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. Phone. '?4 -
Property Address: n
Name of Park:
Parcel: lot Number:
PIN:
Stat~.Road Number. State Road Name:
SW DW TW (Size X-7 # Bedrooms Ye
You signature below certifies that all above information is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
-)Quthorization of Existing System
nature o ronmental Health Specialist Date
~~d 10/06
Application for Existing Septic System Inspection for a Mobile Home Park
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.