ETApplication #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic System Inspection in a Mobile Home Park
Applicant NarTle: , 4)-.-2
x e! 2- Date:
Address:
Telephone:
CHM
Property Owner: U,)' 11'A �'s M )'t� M Phoneld-da?-70-
I L AA
LotAddress: 91-0 -�OOT11"C- �D-'h-&.Ve
Name of Park: C-F'g�fl' L-)n u)A)-S Lot &mber:
Parcel: PIN: it
SW DW TW (Size x-_L4f-) # Bedrooms � Year—v?A�
Power Company: (For Progress Energy we need the premise numbe
T
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. i
You signature below certifies that all above information is correct.
Signature of owner or authorized agent:
Authorization of Existing System
gnature of Environm6ntal Health Specialist Date
x/08