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Applicant Address: Telephone Application # Harnett County Central Permitting PO Box 65 Lillington, NC 27546 , 910 -893 -7525 Fax 910 -893 -2793 www.hamett.org/permits Application for Existing Septic Tank In a Mobile Home Park vq.or�,—qI() Property Owner: ( !�� Phone: Lot Address: _ -/'? Name of Park: T n �n r +' - 4p H A' U- i Lot Number: q- Name 1 o 065; -V oo ►G 19' PIN: 0�"S - &.A - J "0' od O �W DW j. TW (Size x , # Bedrooms Year -.tq - Power Compan kt� ,t' 1•&-L 61e'A-rc (For Progress Energy we need the premise number.) Specific Directions to Job from Lillington: k-� ari� i�[��,.�'�,., t`�h` Q�i fl nj�„��j�i, t'riSS (- othr�' Lion n� n!b_uun `4�- � %`�Da Cfirt►�4 �rfs1 C[b VU -i Ctn e. r i h ©u �A! i se,✓ i n e. o r�s�- er � 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 inforryotion is correct. Signature of owner or authorized agent: 4414X, DO NOT SIGN BELOW - FOR OFFICE USE ONLY Authorization of Existing System Signature bf Environmental °Health Specialist I Date A 'j SEPTIC a 4/08