SEPTIC Application # /o 5 2 297
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910 - 893 -7525 Fax 910 - 893 -2793
www.harnett.org/permits
Application for /
or Existing Septic Tank In a Mobile Home Park
Applicant Name: �tS rT Salav&nt l mv4e z Date: V 1 IZ3120 1 v
Address: e6 Minn Dr Frtack . j
Telephone: @As) %sin 9,24k
Property Owner: 4:9 ..i Ms& ,f , A_.eir r4.° : P
Lot Address: eb Brt& nicks al Mb
Name of Park: Lot Number: 8
Parcel: U 5 T) 063 PIN: 94 -Y7. - Z /2, ag,
V SW _DW _TW (Size 14 x,7 # Bedrooms 7 Year I F3 7
Power Company: Up (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington: ey `, , 443
14-s stn tie. Ve
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 informatio jj . ct.
Signature of owner or authorized agent: //
DO NOT SIGN BELOW — FOR OFFI USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
4 1 /9 7 17
SEPTIC tf--- ------
4/08