ET RApplication #
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:
Date/�/d
Address: dQ fttvz "4 -
Telephone: -aso -
Property Owner: -D--Au'?J
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•Phone: gd- VZ-?
Lot Address: 30
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Name of Park- Vt 11.0—
Lot Number: I f_-
Parcel: 0
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PV. ...... ......... PIN:-
-,- �SW —DW TW (Size #Bedrooms 2— Year
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.
I
You signature below certifies that all above information zcorrect.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
-�/ --&F 6, —/ -7 —/5—
ature OT Environmental Health Specialist Date
J11, '1111:�'
SEPTIC
4/08