ETApplicant Name
Address:
Application # {0 - -
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Date:`/ ld
b ZS 4 J-e&L _ C
Telephone: `'l / 7
Property Owner: Mt -s i J t~s-r
Lot Address:
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Name of Park: Y", "w-5 ~rI /Y ivA(LJ L Lot Number: -0YE- - 2
Parcel: d'3 a51 Co o lol PIN: cOT1-(o0- 5 35 3.000
SW DW TW (Size x-&-5) # Bedrooms Year-( ?*J1 /
/ower Com an • /1'1 e..--- T-
p y ~ (For Progress Energy we need the premise number.)
You signature below certifies that all above
Signature of owner or authorized agent:
"~~V
Authorization of Existing System
Signature of
V C-:, A5
Health Specialist
Date
~l 13 111D
S
is
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
OV l5P "L--
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. ,