ETSEP-15-2016 03:23P FROM:000NTRY FAIR HOMES
TO:919108932793 P.1
Application #
CJ Harnett County Central Permitting
PO Box 65 Ullington, NC 27546
910-893-7525 Fax 910-893-2793
www.hamett.org/pormits
Ap icffiion for g Septic Tank in a Mobile Home Perk `
Date 1
Applicant Name:
Address:
Telephone: S I'D
Property Owner: Z U n ~`T hone:
i ~1
Lot Address:
Name of Park; Lot Number:
t~ a - O `7 O 00
PIN:
Par .
SW _ DW 1'YV (kizex # Bedrooms Year
Power Company' V (For pm9~ orgy we need the premise num~r.)
You signature below certifies that all above info on is Correa'
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
a~ 2d~d
Date
Sig ature n v i r o n enta Health Specialist
, 70C 4W
S
There is a $1130.00 charge for this service. This rtll ~tllMiorm Information isoprrevocation If ovtded on this
Intended use of the septic system changes,
application.