SEPTIC Application # r ` 2 ' 5
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910 -893 -7525 Fax 910 -893 -2793
www.harnettorg/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: i. )011 vita flirt /0+c1 Date: /0 . //
Address: Sad a (' .4 1 Sp; nq % 12r) ro4s4= a• l
Telephone: 4qq 519 -
Property Owner: c )O h n✓l' 1'ird)-0 l �, 1 Phone: Ll Og g19g
Lot Address: FD 0166, Lnn . 107
Name of Park: R n es m {-4 P Lot Number: X07 b A
Parcel: O 3 9C 7d N Ol PIN:
lAW DW _TW (Size ) x 76) # Bedrooms 3 Year /f
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinoton:
Hwy ai tr,t.�ca�rf F4wy A n n a.hnL 'l7 niL g`I
J J on \, (boA : a..; L.
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 ation is c rrect.
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
SEPTIC 4/08
o 7 /I Z X33