ET41ED
Application # 10 - ' '14DI0
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: D4 r►~ Ph ne:
Property Address: `
Name of Park: Lot Number: -
2-Parcel: PIN:
State ad Number: State Road Name:
SW DW TW (Size x-Lt?j # 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 info do is cormat.
Signature of owner
or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Aut ization of Existing System
~t.
J~: qt l
Sign ture of Environmental Health Specialist
Date
10/06
Application for Existing Septic System Inspection for a Mobile Home Park