ETApplication # ELL 7a
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic System Inspection in a Mobile Home Park
Applicant Name: dt ~ Date: (P - ~G - in
Address:
TelephonE
Property Owner:
Lot Address: V\ Air/ 10
Name of Park: 5
Parcel:
Phone:` ` - '
Lot Number: 1-Vj
PIN:
-1-'SW DW TW (Size # Bedrooms Year6JQQ0
Power Company: 1ec~. (For Progress Energy we need the premise number.)
Specific Directions to Job from Liilinaton:
t101~
You signature below certifies that all above information is correct.
Signature of owner or authorized agent: Q _ -
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
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.