ETCA I Application
IHarnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic System Inspection in a Mobile Home Park //
Applicant Name: t I/1 Date: Lo — / % z! ,
Address: e% �� K ��Q
Telephone: — %3 /-O n 7
Property Owner:
t Phone: //0 — 36e-2 y%h
Lot Address:
Name of Park: 1�2� 1�i2 1^-P Lot Number:
Parcel: C/ PIN: q 5-1S'Y '��
SW _DW _TW (Size H x)LPI # Bedrooms 3 Year
Power Company t/ZMgm� 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 infoppation is correct
Signature of owner or authorized agent:
Signature
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
Health Specialist Date