ETApplication #I U 50 V ��L 0
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 UUJ1 �i-
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
Application for Existing Septic T''''
aIInk in a Mobile Home Park
Applicant Name: tel) oaoni(yl Mu CT Date: /J- Z/
Address: 0q5
p �` y- 6 -C -J �'_ i l �j VC1(. cy-) r�qj �Cp
Telephone: ,1 � l,�S .
Property Owner: / q Tr; C/'rX /Do Phone:
Lot Address S%r n u e lv+--->/e5 /Fve__
Name of Park: E/G7&74' �Ii 4 A'/0 Lot Number: o�
Parcel: "I U�� Q� 1 �a- f"
PIN: gss'5-ol-
W DW _TW (Size x �Y �) # Bedrooms r� Year 1 9
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinoton:
74-e/,n on (5AerwootJ
%ten 4-al�noi4inw �lAn 1
frk, lec Par k ) Sf /Of o n
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 information is correct.
S nature of owner or authorized agent:��—f
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
oAuthorization of Existing System
Signature of vironme ealth Specialist Date
SEPTIC
4/08