ETApplication #1
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: _]_.0 L3.'-- A e t� • Rc�.rr, c, C Date:. 'S - 1
Address: Lv o t r, X.0-
r.'-0.r�'�r
Telephone: ` L
h
Property Owner: i Phone:`'%
Lot Address: c�c�
Name of Park: :xp1 C-'n� ('VA- 14 Lot Number: _
Parcel: PIN:
_ SW DW TW (Size �'�- x- l,r) # Bedrooms Years CJ,_a
Power Company LIB 'Fr t-) !E? !iii (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
t'i' 1CA- Csy ie.=i
There is a $100.04 charge for this service.
intended use of the septic system chant
application.
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!wryer Fi�Uma h c�ek _g A- ke- yLoecy
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This certification is subject to revocation if the
les, or if false information is provided on this
You signature below certifies that all above information is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
SEPTIC 4/08