SEPTIC Application # I o - 5 oo -QS I S3
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 gNNEE3
910 - 893 -7525 Fax 910- 893 -2793 411_1_12---
www.harnettorg/permits DATE
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: eti -WML/ An/ c /a /S LLt- Date: 91(
Address: go 79 CILA ,T4-*Aw � Jt r2 714.7 un - (44 iv/ a75 a75
Telephone: 419 - S f) - 64 ( r
Property Owner: Cum. U' 4 b-eV LL Phone: 9 f q - -a - - 7G 4 {o
Lot Address: L/L( twd /rs c T C4'4 2-1 (
Name of Park: - tRAdret $ 1u 14 /HoG tc (d am+ /wtt Lot Number: y
Parcel: Oirfd 0 no 5 oI PIN: 1Wo 2(a- 400.
_ V DW _ (Size 29 x ) # Bedrooms 3 Year 01 I
Power Company: ?tactic-45 (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
(�W y 2 7 Ilea. 10445 ASck.(- 2 ,n1' (-' s el&
its t RcL r ( ' e/ Mi Cie 1 AIns 13 /6.-FF fit 0W e ({a"r /'A o A, lerISAk
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 inform Lion is correct. der
Signature of owner or authorized agent: ( _ `��
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
SEPTIC 4 /08
NAME: CU tie - W , » be ✓'lopt Y G L APPLICATION 8: I`O' ZSt `5I.
This application to be filled out when applying for a septic system Inspection.*
County Health Department Application for Improvement Permit and/or Authorization to Construct
IF THE INFORMATION IN THIS APPLICATION IS FALSIFIED, CHANGED. OR THE SITE IS ALTERED. THEN THE IMPROVEMENT
PERMIT OR AUTHORIZATION TO CONSTRUCT SHALL BECOME INVALID. The permit is valid for either 60 inonths or without expiration
depending upon documentation submitted. (Complete site plan = 60 months; Complete plat = without expiration)
910 - 893 -7525 option 1 CONFIRMATION ft
❑ Environmental Health New Septic SvstemCode 800
• All property Irons must be made visible. Place 'pink property flags" on each comer iron of lot. All property
lines must be clearly flagged approximately every 50 feet between corners.
• Place "orange house corner flags" at each corner of the proposed structure. Also flag driveways, garages, decks,
out buildings, swimming pools, etc. Place flags per site plan developed at/for Central Permitting.
• Place orange Environmental Health card In location that is easily viewed from road to assist in locating property.
• If property is thickly wooded, Environmental Health requires that you clean out the unde►arowttt to allow the soil
evaluation to be performed. Inspectors should be able to walk freely around site. Do not grade property.
• All lots to be addressed within 10 business days after confirmation. $25.00 return trip fee may be insuring
for failure to uncover outlet lid. mat* house corners and property lines. etc, once lot confirmed ready,
• After preparing proposed site call the voice permitting system at 910 -893 -7525 option 1 to schedule and use code
800 (after selecting notification permit if multiple permits exist) for Environmental Health Inspection. Please note
confirmation number given at end of recording for proof of request,
• Use CIIck2Gov or IVR to verify results. Once approved, proceed to Central Permitting for permits.
Environmental Health Ex/stne Tank Insaectiong Code 800
• Follow above instructions for placing flags and card on property.
• Prepare for Inspection by removing soli over outlet end of tank as diagram indicates, and lift lid straight up (if •
possible) and then close back down.(Unless inspection is for a septic tank in a mobile home park)
• After uncovering outlet end call the voice permitting system at 910 - 893 -7525 option 1 & select notification permit if
multiple permits, then use code 800 for Environmental Health Inspection. Please note confirmation number given
at end of recording for proof of request.
• Use CIIck2Gov or IVR to hear results. Once approved, proceed to Central Permitting for remaining permits.
S •
If applyi - _ or authorization to construct please indicate desired system typc(s): can be rank in order of preference, must choose one.
{_) Accep {_} Innovative (_} Conventional y
{_) Alternative } Other
The applicant shall notify the loc. , . th department upon sub6iittal of this application if any of the following apply to the property in
question. If the answer is "yes ", applican • UST A 11 SUPPORTING DOCUMENTATION:
YES (_) NO Does the site contai • : ny Ju ' tional Wetlands?
(_) YES {_} NO Do you plan . ave an jpiaatinn system • . or in the future?
{_)YES { NO Does or the building contain any duke PI -.:. ..lain.
YES { NO Are 1 • re any existing wells, springs, waterlines or Waste : Systems on this property?
(_} YES (_) NO 1 any wastewater going to be generated on the site other than do tic sewage?
{_IVES (_} NO Is the site subject to approval by any other Public Agency?
{_} VES I 0 Are there any easements or Right of Ways on this property?
(_{ YES (_) NO Does the site contain any existing water, cable, phone or underground electric lines?
If yes please call No Cuts at 800-632-4949 to locate the lines. This is a free service.
I Have Read This Application And Certify That The Information Provided Herein Is True, Complete And Correct. Authorized County And
State Officials Are Granted Right Of Entry To Conduct Necessary Inspections To Determine Compliance With Applicable Laws And Rules.
I Understand That I Am Solely Rnponslble For The Proper Identification And Labeling Of All Property Lines And Cornen And Making
The Site essible So That A omp- l/eetttee Site Evaluation Can Be Performed.
Zi g y,a 7 —ga PR e ;` OW E' • R OWNERS LEGAL REPRESENTATIVE SIGNATURE (REQUIRED) ATE
5/08