ETApplication #
l o - 5 0-25 t 3~
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 910-893-7525 Fax 910-893-2793
www.harnett.or _i~ -
g/permits Li AT:
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: 0-6 re - Gt/o t P NeVp / ~ n+ ~N f5 t ~ Date. u
Address: uqUA ~IAX';VA IYI ?-75 6
Telephone:
Property Owner:
u,t a
• ty~LL ~+'t/
.41-<-'
Phone:_
Z67 - 7(~ o
Lot Address:
,vg
s ti c T
C' OA (-5
/Vr~,-
a S
z
Name of Park: -BRA ex-) 81,4 f~ /94-,U l4atf PmL Lot Number:
yo
Parcel: 4? rid O oo 5 I al PIN: l (oI O- 2. V q 011. o op
SW VDW TW (Size 2 9 x-4_) # Bedrooms -Y_ Year 9 °t
Power Company: 1"4sS (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
/-4w 7 T~•Pa aa-ES Ad,ok~f 2 IN" P-
2r,5 k-q ir R-L mot, leis
There is a $100.00 charge for this service. This certiflcation 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 tion is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
9-
,/Signature of Environmental Health Specialist Date
rt J