ETS� I tet' Application #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Applicant
Address:
Telephone
Application for Existing Septic Tank in a Mobile Home Park
Property Owner:
Lot Address:
Name of Park: L
Parcel:
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Power Company_
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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:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
A�!��- � r os l�
iat� ure of Enviro ental Health Specialist Date
SEPTIC 4/08
5/6�1�
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