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Application # 'r Z 2,
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910- 893 -7525 Fax 910- 893 -2793
www. h a rn ett , org/perm its
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: D ( Date: 31 �
Address: a�_ fl l�`ts yJC)eP-0j7 �.. a752g
Telephone:
Property Own(
Lot Address:
Name of Park:
one.« �K- I � IV
ber:
Parcel: PIN:
�SW DW TW (Size . tax) # Bedrooms_ Year
Power Company: (For Progress Energy we need the premise number.) .
Directions to Job from Lillington:
tiC> NL
Y!
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 information is orrect.
Signature of owner or authorized agent:
SEPTIC
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
e';' AL76JOW V6 �_f
re of Environmental Health YSDecialist Date
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4/08