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Application # (o _S c o. q --I
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnen.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name:
Address: 8Q ~ Date s ~d
1
Telephone:
Property Owner:
Lot Address: Phone:
Name of Park: rq,~,o rS
P~~H : IL Lot Number: 17
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C771 tot C) (ooS
SW DW
TW (Size l`1 x_) # Bedrooms 9-
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Power Company: Year
(For Progress Energy we need the premise number.)
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There is a $100,00 charge for this service. This certification Is subject to revocation
intended use of the septic system changes, or If false information Is if the
application. provided on this
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
or environmental Health Specialist
Date
' /es.
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