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Harnett County Central Permitting
PO Box 65 Liilington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permits ll1l�� D
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: /'�i�tu �� b Date:
Address:_ �d
Telephone: S3 '
Property Owner: Jing
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Phone:
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Lot Address: -� 0 y
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Name of Park: Bld e "Wf dO H r Lot Number: aiO!� Y
P cel:lzl (D � ( 6-300PIN: Cr I I- O1- 2('00 , O U�
SW _DW _TW (Size -AX -116 # Bedrooms I Year J %% p"; v
Wer Company: (For Progress Energy we need the premise number.)
There is a $100.00 charge for this service. This certlfication Is subject to revocation If the
Intended use of the septic system changes, or it false information Is provided on this
application.
Yousignature below certifies that all above inf mattpn is coact.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE ONLY
Authorization of Existing System
13, /? 1740-0-
Signgn t� vironmenta Health Specialist Date
SEPTIC
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