ETApplication # / �-g 5 2 p5-
Harnett County Central Permitting
PO Box 65 Liilington, NC 27545
910- 893 -7525 Fax 910- 893 -2793
www.harnett.org /parmits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: OniaAam Grecki'rrlcb,Je. Q. Date• 14
Address: V1 P
Telephone: c � l
�wcradL�
Property Owner, $CY`�� Phone
Lot Address: (-))-„
Name of Park: /1�� ,JV3a►n Lot Number: -!i-44
Pare /el:
�i" �l r��i`�l���' PIN:
sy DW TW {Size I !i A 4 o 1 # Bedrooms cp,--_ Year 8 S
Power Company: (For Progress Energy we need the premise number.)
Snecifir Direr ions to Job from Lillin ton:
i _ i n ki
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 information is correct.
Signature of owner or authorized agent: --4PJ'gVML
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist ate
4108
SEPTIC