ETApplication # 10--SVO"2yZ3L
Harnett County Central Permitting
5 PO Box 65 Lillington, NC 27546
DATE 910-893-7525 Fax 910-893-2793
www.harneft.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name:
ate
Address: It c b(~?~ `'71 n ~nY~1► c~27A-
Telephone: '776 - 33a(
Property Owner:
Lot Address:
Name of Park:
Parcel: X99 5 5 (n ON 9~- 0 t
M-775- 3Sgi '
Lot Number: jot
PIN: g55(o-~Lb-573&-0O0
✓SW DW TW (Size ~x# Bedrooms - 2_ Year 1~~
Power Company: Omhal Fla- - (For Progress Energy we need the premise number.)
You signature below certifies that all above
Signature of owner or authorized agent:
is correct.
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
G
w awl n Q
ign ture o nvironmental Health Specialist ate
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.