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7~ B I O Application 0 --SO _`Z~{-78 S
DATE
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: A1- -Z -r-
Address: > -1-.,
Telephone: q!9 - ~a _
Property Owner: )I ±
Lot Address: l a4 I A Phone:
7J '7 //0
Name of Park: _J V" b M H P
Parcel: Lot Number:
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PIN:
.Sj'4
- LSW DW TW (Size 14 x (n4) # Bedrooms _ 3
PowerCom an : p Year__(g rQ~ . 000
J --.(For Progress Energy wen ed the premise number.)
S ecific Directions to Job from Lillinaton:
G L~
~c
There is a $100.00 charge for this service. This certification is sub ec to
revocation intended use of the septic system changes, or If false information Is prviedif the
application.
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
F nature of Environmental Health Specialist -Il.,. v
xi.s Inc