ETApplication #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
Application for Existing
Applicant Name:
Address:
Tank in a Mobile Home Park
Telephone: ?` m/- 60-x- '-f C/S-
Property Owner: Phone: 91 '5" PS _7
Lot Address: e K- /41 - _ p z., aA C
aG
Name of Park: 6 4 '*J -%1Lot Number:
Pa�rc� PIN: CiCo _(�r� g3�D•O
V SW _DW TW (Size x # Bedrooms , Year
Power Company: 19U F -f- (For Progress Energy we need the premise number.)
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There is a $100.00 charge for this service. This certification Is subject to revocation if they
intended use of the septic system changes, or if false Information Is provided on this
application.
You signature below certifies that all above infor-m�aation is correct.
Signature of owner or authorized agent: R Q- %f
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existin System
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Si ature of Environmental Health Specialist Date
SEPTIC 41011 _ \