ETApplication #.] lQ Sua3 � -(p
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.hamett.org/permfts
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: _L P Dated f!-�
Address: _Z25Q A/P 027 G/ .S ,e/SVCQ AA2
Telephone: _'Flo /308 aClfA
Property Owner:cl/.A'J11N ,�[ phnno•
Lot Address: &/`7r
Name of Park: �t.�STSId6 A' Lot Number:.
3
Parcel_ 2 4S'7.T m/�S/O PIN:g^�lsj6�LS� -DOS
SW _DW TW (Size x 8Q) # Bedrooms Yearaa?�
Power Company: (For Progress Energy we need theT
Promise number.)
There is a $100.00 charge for this service. This certification Is subject to revocation B 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
ulhorization of Existing System
S/ ignature of Ert . onmental Health Specialist Date
M,
'ReC .ck
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