ETApplication #
Harnett County Central Permitting
Pd Box 65 Liilington, NC 27646
910 -893 -7525 Fax 910- 893 -2793
www.harneft.org/permits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: Cate:
Address:
Telephone:
Property Owner: tC t rI \J D
Lot Address: q V1 f -1
Name of Park:
Lot Number. !�2'
Parcel: 0 -0� 21 '� 14 67`) _ PfN: „ —SW ,__,__,DW ---Lm (Size fix. ) # Bedrooms Year q9C
Power Company: (For Progress Energy we need the premise number.)
SpecifiG Directions to Job from Lif in on:
l -t�
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"iiat is pock
Signature of owner or authorized agent:
DO NOT SIGN BELOW – FOR OFFICE USE ONLY
Authorization of Existing System
S' ature of Environmental Health Specialist Date
SEPTIC
4/09