ETApplicant Name:
Address: _
Telephone:
Application 902'3A tI /
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910- 893 -7525 Fax 910 -893 -2793
www.harnett.org /permits
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Parcel: PIN:
_)!�fS'W DW TW (Size 1x 7D #Bedrooms Year
Power Company: k ° „ (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
There $100.00
intended use of the septic system changes, or if false information is provided on this
ap
You signature below certifies that all above information is corre
Signature of owner or authorized. agent:
Authorization of Existing System
ghature of Environmental Health Specialist Date
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SEPTIC
4108