ET~EQ Application # (0-50-Z~I Z~
1D Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: A- J.
Address:
Telephone: 419 -
Property Owner: D--=-1=! n 5
Lot Address: Phone:
~ ~ow 1
Name of Park: 04 M H P Lot Number:
Parcel:
PIN
_ .
SW pW :
_T W (Size =L-4--x-A-0-j # Bedrooms_
Power Company~,r„
(For Progress Energy we n
S ecifi Directions to Job from Lillie ton:
There is a $100.00 charge for this service. This certification Is subjec
intended use of the septic system changes, or If false information
application.
You signature below certifies that all above information is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
iggnature of Environmental Hea ,o6o
Authorization of Existing System
ar-gft~) -
the premise number.)
t to revocation If the
is provided on this
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