ETApplication # V4-
Harnett County Central Permitting
PO Box 65 Liliington, NC 27546
910- 893 -7525 Fax 910- 893 -2793
www.harnett.org/pormits
Application for Existing Septic System Inspection in a Mobile Home Park
Applicant Name: I n&
Address: Rakl' nr YW
Telephone: I O %4 - cos a
Property Owner: -Jgna F{ q n
,
Lot Address: Tslqqa � C�
Name of Park: 2cL-Ynn1r (VtA06 fil
Date: a- a - I.
Lot Number:
Parcel: L1 l =u UUo ( )A PIN:-U2614- 'ALA - �
SW DW TW (Size x10) # Bedrooms Year Ig
Power Compan �13tr (For Progress Energy we need the premise num
Specific Directions to Job from Lillington:
X105 t �Q C 11-10 Y
There is a $100.00 charge for this service. This certification is subject to revocation If
intended use of the septic system changes, or if false information is provided on
application.
You signature below certifies that all above infqpT(a-Pbn is cyfe ;.
Signature of owner or authorized agent:
D NOT SIGN BELOW - FOR OFFICE USE ONLY
thorization of Existing System
Signature of Environmental H h Specialist D to ---