ET1 Application # of 8 U CIZ)
1 u f O Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Date:
Applic,
Add re;
Teleph
Property Owner: Phone: 706
Lot Address: hW4 CT
Name of Park: Lot Number:
Parcel PIN:
SW ✓ DW TW (Size Q_x A # Bedrooms 3_ Year
Specific Directions to Job from Lillington:
'X)l ~lh Turn le4 do Tlo-x Rol apv AM .5 m,)~ j~
PAr 's
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 i r atio is rrect.
Signature of owner or authorized agent:
T SIGN BELOW - FOR OFFICE USE ONLY
rization of Existing System
1d1"161
Signature of nvironmental Heal pecia list Date
5/ 7
/0//-1/07(Z
Application for Existing Septic System Inspection for a Mobile Home Park