ETApplication # '
I'rr�4t1- * Co a cosi l S�a
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546to
910-893-7525 Fax 910-893-2793 1
www.hamett.org/permits
Application for Existing Septic Tank in a Mobile Home Pik /�'
Date. — L2-
Applicant Name: 4 '�
Address: -I- " "` - _ L
Telephone: 7
� Phone.
Property Owner: -jot-
Lot Address: -9
Lot Number.
Name of Park:'
i 41 PIN:
Parcel: � Z � Year
—
S TW (Size _ x ��) #Bedrooms �_ —
_SW we need the premise number.)
Power Company' (Por Progress Energy
revocation
the
There Is a $100.00 charge for this service. is r f falseion infarmato®n isct opravlded onfthls
Intended use of the septic system changes,
application.
You signature below certifies that all above information i rrect.
Signature of owner or authorized agent:
ZLe
71,k ,.
• • •
Authorization of Existing System
-71
gyiature of Enutronmental Health Specialist
SEPTIC
4/08