ETApplication # l M)0 S7 6'6_E
7
Harnett County Central Permitting C(f�l 3 /
PO Box 65 Lillington, NC 27546 � pp
910-893-7525 Fax 910-893-2793 --7—) (Q VJ
www.harnett.org/permits
for Existing Septic Tank in a Mobile Home Park
Applicant Name:
Address: 11)V5_11 \ it>
Telephone: X110
Property Owner AIC k
Lot Address: 7
:6°1 io q(L-(— Z(t� �1)
Name of Park: (J6 \u t)u V-Jce�A- Lot Number: �cc
Parcel: TT -59' (AIAT-6X0 PIN: 07658 W
007q
SSW DW _TW (Size l L x ) # Bedrooms � Year 'q .
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinoton:
- C a"C:
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 agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
gnature of Environmental Health Specialist Date
SEPTIC
4/08
)NI 1,N