ET••• • I —• I
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910.893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: ✓6 NA Date: /h
Address: d J(2
Telephone: g h) , 635 -
Property
35 -
Property Owner:��lQS /aid Jnq Phone: �/7 - 398' R 6
Lot Address: & b B a tJ �r (. /
Name of Park: z Lot Number: Ln+ 61
Parcel. 3 PIN: — dQQ
_SW W _TW (SizeaL_x_�J # Bedrooms Iq Year a D1
Power Company v.V'a Esp[i I (For Progress Energy we need the premise number.)
Specific Directions. tooJob from Lillin ton:
OA/:,7,7
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
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
uthorizati/o/n�of Existing System
C
Z2��=
Signature of EhWronmental Heath Specialist Date
sESEPTIC��� ZZ
z3