ETOct 20 14 10:32a
Applicant
Address:
Telephone
Jane 919 - 498 -3658 P.2
Application # 7 1
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910 -893 -7525 Fax 910- 893 -2793
www.hamett.org/perm its
Application for Existing Septic Tank In a Mobile Home Park
Property Owner:
Lot Address:
XA1 of Park :.,�
,/:( [
✓ SW DW
Power Companwl
IWAd or '- 4X6612 - Lot NuMber: JL
7LI,2, 00 0 �?a�,rc+e.r OB d
TW (Size N x} # Bedrooms` Year
(For Progress Energy we need the premise number.)
There. Is a $10 0.00 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 correct.
Signature of owner or authorized agent: AA4 A.
SEPTIC
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
L=L= ,a Y;L - XO /,77 12--Iq
Sig ature o nvironmental Health Specialist Date
4108