ET2 _ Application # J (4 , )6 33 3 aF
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Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910 - 893 -7525
Fax 910- 893 -2793
Application for Existing Septic System Inspection for a Mobile Home Park
Date:
Name:
Address:
Telephone:
Property Owner:
Property Address:
Name of Park:
Parcel: /
State Road Number:
SW DW _
%D�rJ Lot Number.-7-7
PIN: -7
State Road Name: Q—
�TW (Size x) # Bedrooms Year
WA
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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 info ation 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
10106