ETApplicant Name
Application #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 ��ao�
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
Application for Existing Septic Tank in a Mobile Home Park
tI%917on
Address: 2lg i!,sLVu� lJc�u�..\e,c� �.. 8123
Telephone: 9t9 - le Ln 5- 851
Property Owner: Lc -<<ti r, % Phone: qty- 89c�• o�VZ
Lot Address: X43 A•�..,. wc:%v� .�
Name of PParrkk:" M. - <, map Lot Number:
Parce �(Z� PIN: n(fD&O - c20- 006
SW DW TW (Size IL -0 x- #Bedrooms_ YearcgCb(o
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
42-\ LJAr o. Cn�� 1 +A
o� 0\d, llS �\i� `Ac,pG� Z • L S i ���
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:
NOT SIGN BELOW - FOR OFFICE USE ONLY
thorization of Existing System
QGrIS ! 3d t
of vironmentala t��i Specialist D to
SEPTIC