ET RApplication # `%p Y
Harnett County Central Permitting
PQ Box 65 liilington, NC 27546
910- 893 -7525 Fax 914-893 -2793
www.'harnott.org/parmks
Application for Existing Septic Tank In a Mobile Home Park
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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 r below certifies that all ibove Information correct.
Signature of owner or authorlzed agent: 2&��
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Authorization of Existing System
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Signs re of Environmental Health Specialist Date
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