ETApplicant
Address:
Application # _
Harnett County Central Permitting
PO Box 65 Llllington, NC 27546
910-693-7525 Fax 910-693-2793
www.harnett.org/permfts
Anollcation for Existing Septic Tank In a Mobile Home Park
Property Owner:
Lot Address: I
Name of Park:
_ Lot Number:
Parcel :316^1—nR L �t�� PIN: 00
�SW ___,_DW ____TW (Size L�x—J t 11 # Bedrooms Year
Power Company: (For Progress Energy we need the premise number.)
Ypecifi Directions to Job from Llilinrttor:
4y(i !ZyW trwtyl Qn h '41 -
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 correct.
Signature of owner or authorized agent:
SEPTIC
00 NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
4na/ur-ezt7 nviroa tial Health Specialist Date
4=,