ET RApplication # 0
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permfts
Application for Existing Septic Tank in a Mobile Nome Parka
Applicant Name: tag Y, k�� t 7ra Date. -7-=Z
Address: l2 1
Telephone: 10 f
Property Owner: Ua r 1/16 , -TA Phone:
Lot Address: `2Z2PWI y1 &cA , G S�-r fn �� h /t -r „�_,• /lI�
Name of Park: Lot Number: `7
Parcel: �'[. ��� 12 PIN: --
UW DW TW (Sizex #Bedrooms__._!:_ Year'Z
Power Company 111 �-(Por Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
S 8u cam_ V �t 4n WQ 4 'G d(larcli. f2D
7LU W2 12141 11-M-5AAd&96�:t� ISD 7 -h& -AJ
e
There is a $100.60 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 rr
Signature of owner or authorized agent: /
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
x,51` Authorization of Existing System
-77- /// ' ,/0-
ature of Environ al Tiealth Specialist Date
SEPTIC 4/08