ETApplication # _ff, ~_~V Z
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www. harnett. org/permits
Applicant Name:
Address:
Telephone:
Application for Existing Septic Tank In a Mobile Home Park
1) C(o4(, Date: /o
9
4oA-.;
Property Owner:
Lot Address:
~0'-rll Phone: _ L ~i9 8193
0-7
Name of Park: _ ~r'ne~ M 4~ P Lot Number: 1414 6 A
Parcel: 74- 7 42l PIN:
--Ie!~gW DW TVV (Size x76 ) # Bedrooms y
Year--(f
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
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 abo77
on is
Signature of owner or authorized agent:
DO NOT SIGN BELOW FOR OFFICE USE ONLY
Z:2~~ Authorization of Existing System
/4ZL P 2 a
gnature of Environmental Health 0! Specialist Date
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