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Application # 5n ~oa~/
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
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Specific Directions to Job from Lillington:
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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: V/J1097 L1111 y
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
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Signature of nvironmental Health Specialist Date
Possible b odeek
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/019 5/07
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Application for Existing Septic System Inspection for a Mobile Home Park