ETApplication #
X5-;f 21
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:
,D
Address:
Telephone: _ 9/
Z9- 7 700 c
Property Owner:
.~fi/Y,P ~NN/S
Phone: /O Z
Lot Address.
Name of Park:
Lot Nu
ber: S"D f~
Parcel:
Z
m
PIN: /b / I ~ 7
_./.SW DW
TW (Size _16~ x-2.`J
# Bedrooms Year-_Zfff_
Power Company:
21
(For Progress Ener
h
gy we need t
e premise number.)
Specific Directions to Job from Lillin ton:
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
'gnature of Environmental Health Specialist Date
SEPTIC
4/09
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.