ETApplication # )!!, - �5 U
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910- 893 -7525 Fax 91 0- 893 -2793
www.harnett.org /permits
Appilcation for
Applicant.Name:
Address:
Telephone:
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Property Owner:
Lot Address:
Name of Park:
Power Company: (For Progress Energy we need the premise number.)
air
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 informat qp is correct.
Signature of owner or authorized agent:
SEPTIC
Authorization of Existing System
Sjgh,'ature of Environmental Health Specialist
Ze-,
Date
4108
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