ETApplication # I py)o 1 1 Z
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:
Address:
Telephone: q L oi- 4.S--t-
Property
3--t-
Property Owner: SAW r, Phone: q101- 4 34 —Ic!% 3°!
Lot Address: I0�0 u G(�i Rd<
Name of Park: Rol, k H p Lot Number: !q
Parcel: PIN:
io SW DW -TW (Size iQ x=1 o ) # Bedrooms 3 Year �DUS
Power Company: ��%Y (For Progress Energy we need the premise number.)
Saecific Directions to Job from Lillington:
e
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. C -Y+ !� rm*— g
You signature below certifies that all above information is correct.
Signature of owner or authorized agent: � ���Me+�L* ry4,A1,4)
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
nature of Envi tal Health Specialist Date
SEPTIC
4/08
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