ETL�- aa-i�0
Application #
Harnett County Central Permitting
PO Box 65 Liilington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing
Applicant Name:
Address: t
Telephone: � - U -
Property Owner:
Lot Address: t k
Tank in a Mobile Home Park
96
Name of Parke �,C 4,(ski Lot Number: 1'-10
Parcel: Ch I t) 515 02r -i—i�►V—
_SW b -C -DW _TW (Size x# Bedrooms _---2)_ Year i
Power Company-S"I uo ✓A
� o , r. r (For Progress Energy we need the premise number.)
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. 1
You signature below certifies that all above
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
J �q so
Signature of Environme Health Specialist ate
SEPTIC
Oros
Z//acq-//P
Is