ETApplication #r5:56 6 `'69c� q,3
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 7 +„
910-893-7'525 Fax 910-893-2793 W
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: �. �' - '�^ M V1
Date-: _��115
Address: �11- t, -2r -,A-,
Telephone: 0 �W- S—
Property Owner: ✓` v s 4-r'yt f}S : /4' - .r P
Lot Address
• „ AN
is / • r
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 information is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
re of Environmental Health Specialist Gate
SEPTIC 4/08