ET\A1 Application # J 1 rso in �� q\
Harnett County Central Permitting
PO Box 65 Ullington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permfts
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: �Ci`N'n`w Q,'(`tl., VY1Csyy* I, j+ Date: —`A --J
• . • .I��R�V•!�•L�i�!'J'!�'�.31L'"«wbA4.s.�a=3�wws.�s.ac-a
Property Owner:
Lot Address:
� , u
455
Name of Park:`L4CA 'e :�' Cc ll&f' �_ Lat Number: 04I
Parcel: hf)5d PIN: 95Ct–t"q$' 1 q'7•fX��
�/,SW ,_DW _TW (Size LLLx%d) # Bedrooms _ Year n G
Power Company: J)c 1<-P t 5[*J cQi ((For Progress Energy we need the premise number.)
`e ✓ K) U
cs�si� niraMinnc to .Inh from I illinntnn[
S'!_ ,04...
Ll 'rt t c"" Tv'
7
I tS �� �2 n f c�Y\ to i �i la n IZ v f a 3 k T,Akh 17j�3 on
rV f
There Is a $100.00 charge for this service. This certification Is subject to ievocatlon if the 12;
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: A (h N- i- ' {
DO NOT SIGN BELOW – FOR OFFICE USE ONLY
of Existing System
L) I -Z"A 1 F
Signature of Environmental Hea ks'pecialist Date
SEPTIC 4/06