ETlk-5-lq Application # I %?-
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Se tic Tank in a Mobile Home Park
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Applicant Name: X-7 Date:
Address: 4-111 1 � /:5- C /�
Telephone: Y/ -
Property Owner: Phone:_ A15
Lot Address:
Name of Park
Parcel. -1 (4 L I ci * PINL�.p(L. A-LDa- IL-
V-,SW-- -DW —TW' (Size/ x k) #Bedrooms Year_L_q_,f 7
Power Compan :�7k�' � kZee=:�3, (For Progress Energy we need the premise number.)
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There is a $100.00 chirgelfor 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:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
�Wnature of Environmental Health Specialist Date
SEPTIC
4/08