ETO Application # ! 00- Soo- 1 -10
Harnett County Central Permitting Z
PO Box 65 Lillin ton 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:
Address:- Date: z
Telephone:u Z z._
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Property Owner:
Lot Address: / d y Phone
21
Name of Park:
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Parcel: O~ Z 0O Lot Number:
-=SW _DW PIN: C(o92-? ygoe, . om
_TW (Size i
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Power Compan # Bedrooms Year1 y`
I r rr S ~.v~r (For Progress Energy we need the premise number,)
pecific Directions to Job from Lillin
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ton
ci l ~ f4j, A .7 ~C' A 'cif
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There Is a $100.00 charge for this service. This certificatl
intended use of the septic system changes, or If false information
on is subject to revocation if the
application, is provided on this
You signature below certifies that all above information is correct.
Signature of owner or authorized agent: _ J
DO NOT SIGN BELOW -FOR OFFICE USE ONLY
Authorization of Existing System
ature of Environmental Health Specialist G 3 G W "
Date
G f Q/ /tom'
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