ETApplication# 3
Harnett County Central Permitting
PO Box 65 Ullington, NC 27546
910- 893 -7525 Fax 910 -893 -2793
www.harnett.org/permits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: O�. H t1 W . ( Date: 6 - --17 --76 tc�
Address: 1_U-4 W-i, MA) , A] L
Telephone: q r 1 I E?& ( -
Property Owner: _0a4.n '_ W, 1_A Phone:
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Lot Address: &7— I -,S , ZZ 1 y�n %1!'�G/�.lkwl - ";/� is=
Name -of Park: Vh i+F Lot Number:?'(
Parcel: Z �,
� � oz os- PIN:
SW DW ®TW x Size
1 { ��1�....,. ��?2.� #Bedrooms G- Year
Power Company�U' -Pt LOP — (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
hr A11 / i I y
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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 corre
Signature of owner or authorized agent:
Authorization of Existing System
igna ure of Environmental Health Specialist Date
SEPTIC 4/08