ETApplicant
0436=79
Telephon(
Application # 1 , - tel, t i � n H
Harnett County Central Permitting
PO Box 65 Ullington, NC 27546
910-893-7525 Fax 910-893-2793
www.hamett.org/permfts
Application for Existing Septic Tank In a Mobile Home Park
Property Owner: Eo'c \ Phone:
Lot Address: .
Name of Park: Lot Number:
Parcel: 01 \ CO U PIN: i L,1 L;
q --SW _DW _TW (Size -A_x-LIQ) # Bedrooms -' Year
Power Company' (For Progress Energy we need the premise number.)
There Is a $100.00 charge for this service. This certification Is subject to revocation it 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 on is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
S Etta ure vironmen Health S is is Da e
SEPTIC
4/09