ETMin,
Applicant
Address:
Application # fi;70 53 2- Y4
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910- 893 -7525 Fax 910- 893 -2793
www.harnett.org/permits
Appllcation for Existing Septic Tank In a Mobile Home Park -
-n oq"MaC. G 7"'" Date: l ° 2-01y-
1 i 1. tr �' _ _
Telephone:
Property Owner: Q ��--5 Phone:
Ci n
Lot Address:
Name of Park:
Parcel: PIN;
4 -"""SW DW TW (Size f x ) # Bedrooms ? Year
Power Company: (For Progress Energy we need the premise number.)
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 informati n is correct.
Signature of owner or authorized agent:
SEPTIC
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
gnature of Environmental Health Specialist Date
�d6�1
4/08