ETI late _
Name _
Address
I clef. huni
OA -
Application # 15 5d0 5-7 o 1
Harnett County Central Permittmy,' "" Q I q 9 0
PO Box 65 Lillinaton. NC 27541
elenhone Number 910-893-7525 �' QQ �(�j is
=ax910-893-2793 Lf,9,11
r.niica}ion for Exigtinq 6entic Sustf-! -• Inspection for a Mobile Home Park
Property Owner, _- 6.4
I'iopeity Adfire:•. .
Name of P r 7
Parcel: 12
State Road Number:
SW-.K..DVV__,_TW
M-3°
Lot Nu
State Road Name:_
_x _4_b ) x Bedrooms
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 farce information is provided on this
application.
You signature below certifies that all above info mation is correeccii .�
Signature of owner or authorized agent:�--
O NOT SIGN BELOW — FOR OF'
OW
lJr l" ONLY
uthorization of Existing System l !
Signature of Environmental h Specialist Dale
S