ETApplication #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Date:
Applic<
Addre:
Teleph
Property Owner:
Lot Address: 3
Name of Park:
P!7-S,.
W DW
aY/01-) l,c
one:(0t\q) S-*-S-S'M
r-4 'si-Ad f4 its Lot N ber:
-
0 M9 PIN: C1165 'V 11
TW (Size x C7) # Bedrooms Year 1
0 h- 4"
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 infgffQion is correct.
Signature of owner or authorized ag
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signat a of Environ ntal Health Specialist Date
s
5107
Application for Existing Septic System Inspection for a Mobile Home Park