ETApplication #
13
• • •-
Application
Applicant
Address:
Telephone:
•M: • - ;1
•, Address:
Name of Park: S
Parcel: �% / l 1z OaV PIN:
SW DW TW (Size x,,,__._} # Bedrooms
Year
,� , "1
Power Company' {For Progress Energy we need the premise number.)
Soecific Directions to Job from Lillington:
There is a $100.00 charge for this service. T�is certification Is subject to revocation If the
Intended use of the septic system changest or If false Informs, 3 ld d on this
application. f� A, W�
You signature below certifies that all
OMMON
�• • c • .teJAW •
Authorization of Existin System
Jtl °2'i ®63
I nature of Environmental Health Specialist Date
SEPTIC 4108
101,5,113