ETApplication #
Harnett County Central Permitting14Q
4
I �
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: As6�Q� BioiswQDate: 1y
Address: r1c"r l�- WOO Ji VC-
Telephone: -S yl( -8 9 � �
Property Owner: Phone:
Lot Address: Sit
Name of Park: bcxdn"4�Lot Number:
Parcel: bE tic55 l 0 PIN: Dac;4%oob
SW DW TW (Size �2'
4 xK 0 ) #Bedrooms - ---), Year
Power Company: (For Progress Energy we need the premise number.)
Sgecific Directions to Job from Lillington:
\'Jvmc i- U 4(vo'j is C
There is a $100.00 charge for this service. This certification is subject to revocation it 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:
SEPTIC
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of E isting System
nature of Environmental Health Specialist Date
A� 4/08