ETApplication #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 WM /s,
910-893-7525 Fax 910-893-2793
www.harnett.org/permits40
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Application for Existing Septic Tank In a Mobile Ffome Par
Applicant Name:
Address: -54E
Telephone:
Property Owner:
Lot Address:
Name of Park:
Lot Number:
7Par I: PIN:
SW _DW _TW (Sizet_ ) # Bedrooms X Year \o t<4
Power Compano h�N: u (For Progress Energy we need the premise nur
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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 false information Is provided on this
application.
You signature below certifies that all above information is correct.
Signature of owner or authorized
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
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Signature o vironmental Health Specialist Date