ET/5-4-�v
Application #
Harnett County Central Permitting
PO Box 65 I-Iliington, NC 27546
910-893-7525 Fax 910-893-2793
www.hameti.org/permfts
Application for Existing
c�Septic Tank in a Mobile Home Park
Applicant Name: 4-f -/- � � � s _.--_--.Date: _
,
Address: aal 42
Telephone:
Property owner:r 'Phone:
Lot Address: �t Y�L!- --� 'h?'� y° - 4r
Name of Park:. Lot Number:
Parcel:% PIN:
SW —4zDW TW (Size Z)'Z x 7d t # Bedrooms Year
Power Company: (Por 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 information is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System 1
c .L ld t 26/J—
Signature of Environments! Health Specialist Date
4/08
SEPTIC .�