ETOct 20 14 10:31a
Applicant
Address:
Telephonf
Jane 919 - 498 -3658 P.1
Application # �—,/v 3 I I 4_
Harnett County Central Permitting
PO Box 65 LiAington, NC 275+48
910- 893 -7525 Fax 910 -893 -2793
www.hamett.org /permits
A piication for Existing Septic Tank to a Atobile Home Park
Property Owner:
Lot Address:
Name of Park: _
1.
DW TW (Size
Power
?� '!7ia -AM
;S10 Numr. be
x # Bedrooms. _,,y_ Year
CGS/ (For Progress Energy we need the premise number.)
There Is a $100.00 charge for this service. This certtfication is subject to revocation If the
Intended use of the septic system changes, or H faire information Is provided on this
application.
You signature below certifies that all above information Is correct.
Signature of owner or authorized agent: Iva
SEPTIC
Authorization of Existing System
Signature o nvironmental Health Specialist pate
4/08