ETApplication #
Harnett County Central Permitting i Q'
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793 b d
Application for Existing Septic System Inspection for a Mobile Home Park
Date:
Name:
Address: 1 ;Z
Telephone: Q11? -
Property
t9 -
Property Owner: J
Property Address:
Name of Park: (Du
Statq,Road Number:
V, SW DW _
or pc I I I {Pc' (- y o
ohnnn• L17i _A
Lot
VC 6Z IC-) Srale Road Name: h
TW (Size x_.b& ) # Bedrooms
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 inform n is
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
?� Authorization of ExisAng System
LZ
Anature nvironmental Health Specialist Date
10/06