ETApplication #
Applicant Name
Address: 3.
Telephone:
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
7
5-YM
Property Owner:/ x
Lot Address:
Name of Park:
Phone:
. Lot Number:
PIN:
TSW OCC
DW TW (Size
x # Bedrooms Year /l
Power Company:
(For Progress Energy we need the Dramiica ni iml,-
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
Sig tur Envirdnmental Health Specialist
ate
'71
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.