ETeq— IS Application # bo 2�s
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
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T M"IFT111
Applicant Name.:
Address:
Telephond: �&g 3-6e
Property Owner: " �/'Mz 4;_t>V_4 —Phone:
Lot Address: 4glCo &
Name of Park: IAKs-7ne 11L_ AV.4 Lot Number: A?
Parcel:(:S 95M S (--
PIN:-q
—SW _DW TW (Size P. x_SYear
YJ #Bedrooms
Power Company; (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
There is a $100.00 charge for this service. This certif Ication 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:
F114-21'rol-Mi - �,' :�e NI
Avithorization of Existing System
'5eA
"19ure of E6ironmeht6f Hath Specialist Date
429
4/08