ETApplication # _ I S So 3 !T9 S 4
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: Wi_ adi nq RiCiT rhes, l Y. (V ng lrn 9. II' "'4ate: H7 - � C •• 1
Address: Pr)N)k 5145 SCS kir; NC a1331- 5145
Telephone: lq lq) 'l-15 q56q
Property Owner: WiiZdt hQ Qi dQ G d1 S+ L,)c_ Phone: (q1q )1-1S i589
Lot Address: 1210 K n� ChQr l� AyP . Ctt lme-voh NC D93DU
Name of Park: nk)thnatgnm MHP Lot Number: (P
Parcel: D9 g555 0U31+t PIN: 9555 - (fl I - a -7 IF c�
✓ SW DW TW (Size I `{ x_ ZD ) # Bedrooms a Year IggS
Power Company__ t► E JC&"G (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
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
' X
—
Signature of Environmental Health Specialist Date
SEPTIC
4/08,8
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