ETApplicant Name:
Address: /7/
Telephone: 15
Property Own
Lot Address:
Application # 1 b IZ0 5 0 1 >'
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.hameft.org/permits
Application for Existing Septic Tank In a Mobile Home Park
Name of Park: Lot Number: /3
Parcel: Z29 9�7, i !�/fK— /o PIN: 7J % ` 83-'LL•r/-
-iY—SW _DW _TW (Size _Z!� _x_ j4) # Bedrooms. SYear &W__
Power Company: %4h c+ZAd1AV (For Progress Energy we need the premise number.)
Specific Directions fn Job from Lillinaton:
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 info tion is correct.
Signature of owner or authorized agent: e&Qi
V
OT SIGN BELOW — FOR OFFICE USE ONLY
orization of Existing System
Signature of Environmental ea pecialist D to
SEPTIC
IIIIIIIIIIIINKly J