ETDate:
Name:
Addre:
Telephone:
Application #I
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910 -693 -7525
Fax 910 - 893 -2793
Application for Existing Septic System Inspection for a Mobile Home Park
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Property Owner: ��. 6�t � ��_G Phone: 91q b��i- Y � ?�
Property Address:
Name of Park: T-e*vh -r,4uj Lot Number: ,2-r"
Parcel: D1 U S(�,[o t x PIN:1-ISLU Scj --,�2 1:3(, R- c)O U
State Road Number: State Road Name:
SW cl-ow TW (Size a e x r a # Bedrooms Year q9 d
Specific Directions to Job from LillinWo :
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 ation is correct.
info
Signature of owner or authorized agent: -, iZ
DO NOT SIGN BELOW -- FOR OFFICE USE ONLY
orization of Existing System
QS S 7 1
Signature of Environmental Hea ecialist J Oate
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