ETApplication # 19SL`W520
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: �12�wfizj,�)1 S Date: /
Address: 9/ Tim � c'__ �;
Telephone: 210 S - i, 4 O
Property Owner: _1�� leek-- s Phone: �1/c7 X93 Sz2 S� Z7
Lot Address: 3 c 7 -
Name
Name of Park: k P& Ill Lz-� xe;, &;;7 Lot Number: S�
Parcel: J I r7l9lo'a. b _jv-4y PIN:ot II0it -CI I - SLIPVC�.Obo
SW ✓ DW _TW (Size �N )VU ) # Bedrooms :_ Year
Power Company: (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
Signature of owner or authorized agent:
SEPTIC
is correct.
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental HealthSpecialist Date
4108