ET RApplicant
Telephom
Harnett County CenPermitting �.� � (a
PO Box 85 LIIli 0010 tral NC 276411
910-893-7525 Fax 910-893-2793
www.hametLorg/permtts
Applk atlon for Existing Septic Tank In a Mobile Home Perk
Property Owner:
Lot Address; _- [/
Name of Park: Lot Number:
t S'!a
Parcel: V"! 9 6 0!Z PIN:
`gyVW _TW (Size 7- xZ� #t Bedrooms T_ Year 1 -
Power Company' (For Progress Energy we need the premiss number.)
There is a $100.00 charge for this service. This certHiation 15 subject to revocation it the
Intended use of the septi: system changes, or It false Information Is provided on this
application.
You signature below certifies that all above Information is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
u01111t, mciAtigt Date
SEPTIC 4M`�1 S