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3 191 1 Application # 10 V SIo0-2q cd b
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Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793 1corj o 0 - -t IF -7 -r'
www.hamett.org/permits (
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: ° _R, ald fz a' Date: 3' 10-'10
Address: L y ~1A / l a A yt5, w c a:21- o 1
Telephone: j t j - - ~ : J / - 5 ~ Y9
Property Owner: f A ;Ad 'j cz k,s Phone: 9 d- S- j
Lot Address: Y 5 a .f L n P v( yV, C
Name of Park: Q411Y Ag{q;
Pa
SW
s Lot Number.
DW
PIN:
TW (Size `k x ) # Bedrooms _ 3 Year tgg b
Power Company: (For Progress Energy we need the premise number.)
Specific Directions 'to job from Lillinato :
C1.eaA C 11XIA C
LINE -9 'A akck -$f CA
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: 4'4
DO NQT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist
SEPTIC
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