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06/25/2015 13:05 0018 P.001/001
Application #_ III Q 150-C) S 959 9
Harnett County Genual Permitting /\ /� , , T 1
PO Box 65 Lillington, NC 27546 Il..�}` - tom, v 1
910-893-7525 Fax 910-893-2793
www.harnott.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: 51:) LticFL M. Twr[ 2 Date: P. 24.
Address: /01/ 62s> 9mok Dr 23232,
Telephone: Boy. 539. ri295
(�ndtny Mµf LL
I Property Owner: S19M T" - L
eAl2 J�'Cig�fS Phone: 80e, S3!f•'f,2-9S
D ' �ot Address: Q 7,/lam Z }S
Name of Park: 't—yQ & Lot Number: # $
Parcel:G3qls'R lll/V . PIN:S9 How
ntif
�--SW _DW _TW (Size x ) # Bedrooms �_ Year I 9 duan WtA in
Power Company: (For Progress Energy we need the premise number.) 10
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 infor tion is correct.
Signature of owner or authorized agent:00
NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
SEPTIC
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