ETApplicant
Address:
Telephom
Application #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permhs
Application for Existing Septic Tank In a Mobile Home Park
Property Owner:
Lot Addressgg,
Name of Park:
If I_ Lot Number: / I
�SW
Parc I: 04 hl o [ r�4 cjL��h PIN:
_DW _Tyy (Suet _x� # Bedrooms_ Year_ D / 7
Power Company; uAlt (For Progress Energy we need the premise number.)
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.
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
Z— z9 —
$Ignature of Environmental Health Specialist Date
SEPTIC