ETApplicant
Address:
Telephon
Application # 6 5-po 3 Z 3,4
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910- 893 -7525 Fax 910- 893 -2793
www.harnett-org/parmfts
Appiication for Existing Septic Tank In a Mobile Home Park
Name: /' t Date • 160 — " 'i/ 3
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jam- ?`
Lot Address:
r
Name of Park: Lot Number:
Parcel: !:0 PIN:
Syy DW - (Size x #Bedrooms Year_ –firs
Power Company: (Far Progress Energy we need the premise number.)
There Is a $1 b0.00 charge for this service. This certification is subject to revocation if the
Intended use of the septic system changes, or If false [Mormation Is provided on this
application.
You signature below certifies that all above infor n is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW – FOR OItICE USE ONLY
.. Authorization of Existing System
of Environmental th Specialist D to
11 A
X1/7 '�'
SEPTIC
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