ET01 , I ': Application #
4-10 —0
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic-Tank in a Mobile Home Park
Applicant Name: ZL 6- /�7e-1,,/ Date:
,- 7
Z Z--
Address: 2
Telephone:
Prop y ert Owner: J v. Phone:
22 ILL
Lot Address:
Name of Park: A-A cw,
- ri- I' - 4/4ZZ, 4!-- Lot Number:
Parcel I G-4 (C) 1 (1-7 PIN: 0 - 115
V'SW DW TW (Size* --- �X=z�) # Bedrooms Year
Power Company: (For Progress Energy we need the prernise number.)
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 I on this
application.
You signature below certifies that all above information is correct.
Signature of owner or authorized agent:.,
Authorization of Existing System
Z
Signature of Environmental Health Specialist Date
9�11
SEPTIC 4108