ETPO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Application for Existing Septic System Inspection for a Mobile Home Park
Date: e-t -2Z P
Applicant Name:
Address: ILkL e,,so,. ~c ~'rsa
Telephone: t q_ q t~_ p~, ti z_
Property Owner: lip AOLA ~b~nt e- Phone: 9t9--79 e- o c Z
Lot Address: _-JZ 1
Name of Park:
Parc I: ~
SW DW TW
90% we.Y cosy
Pre mwe #
IF Nogrett
claw
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:
~hAll V
4.4.- Lot Number: )
PIN:
x o # Bedrooms Year 1
DO NOT SIGN BELOW FOR OFFICE USE ONLY
Authorization of Existing System
rig~atur~eof Environmental Health Specialist Date
5/07
A
Specific Directions to Job from Lillinqton: