ETApplication #_ I L ncaO 'M -V
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: — yN+H % Jnr Rr» (50A kL-C Date: %
Address: P, D r
_ B„ 14 R Ce I- Z-7507
Telephone: a lq - 4-54- ol-1Sof
Property Owner: j aA O'
Lot Address: 101,4- R P.rrn1,eA ' R„y 4)2a , r C 1..1 C.
Name of Park: �nc� &M.,o. Lot Number: 1 D
Parcel: PIN:
SW _DW _TW (Size _4_4__x %o j # Bedrooms 3Year l `l o
Power Company; LJ Inde- Lin r,,. , (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
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 xisting System
re of nvir nme tal Health Specialist Date
SEPTIC
4108