ETApplication #I t��?S-7 4S
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name:
6114
Address: I&)$- 0-T 1L'JVLA .
Telephone: 2 A — -7/0 - / U ,� S—
Property Owner: t t� e -S -� t�n��• -�-5 Phone: �M - 7/0
Lot Address: r .�, .� 'Z� LbCLL�2 i I (.Q.l\S�,
Name of Park: < e, e,�' _ Lot Number:
Parcel: cel I S;kkPIN: ISSll " LQ9
SW DW TW (Size x a # Bedrooms 2 Year Z 3
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 informati is corre .
Signature of owner or authorized agent:
SEPTIC
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existin System
i ature of Environmental ealth Specialist
Date
4/08