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**,me Application # Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Date:
Applic4
Addre;
Teleph
Propeity Owner:
Lot Address:
Name of Park-
Parcel: 046
SW DI
c 6c o -uaw,cy Phone: q tG - C402- JTS~~
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PIN: O - pQ
.TW (Size QS x 49 # Bedrooms 3_ Year -,1D0 (P
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:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
nature of Environmental Health Specialist Date
/OX ~ 3 W
5/07
ire
Application for Existing Septic System Inspection for a Mobile Home Park