ETf Application # I Is sd� �s L/
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
App11 ation for Existing Septic Tank in a Mobile Home Park
Applicant Name: Date: (- 2.9 - t
Address: A-7rr1
r�r A i Ill Jr �'r c c,% iA )
Telephone: -Lo -
Property Owner: -Vp6Z g�'a-
Lot Address: Ci,�- Irc
Name of Park: ��D r�r�/rs r10C
Parcel: b'� dsT�q LC -�(
am
5
Lot Number: 3
PIN:
L--�SW DW TW (Size / Zx 5 W ) # Bedrooms Z- Year 1j�
Power Company: (For Progress Energy we need the premise number.)
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.
You signature below certifies that all above info a 'on is orrect.
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existin System
of Environmenta Health Specialist Date
a'r
SEPTIC 4/08 Ley"