ET RApplication # 1L19_:;(()_2_3U U1S
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 049910-893-7525 Fax 910-893-2793
www. harnett.org/perm its
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name:
Address:
Telephone: '
Property Owner:
Lot Address:
Name of Park:
r
� Phone: 9'/ /0-
-
-
SW DW TW (Size/,�e _x S!o) # Bedrooms __ Year / 9 f 7
Power Company:-,� XPj7 &q (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.
You signature below certifies that all above information is
correct.
Signature of owner or authorized agent: t//Z c -a 7�
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
�Authorization of Existing System
re of Environmental Heath Specialist Date
SEPTIC 4/08
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