ETApplication # ~o- 5CO-295 00
` NED Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
aAT` 910-893-7525 Fax 910-893-2793
www.harnett.org/permits Gtr
74te-~lt\ 2
Application for Existing Septic Tank in a Mobile H~ Park
Applicant Name: hZ- ~+g v ~ u ~paiA9 Date: / 0 X~// 0
Address:
6r
Telephone: Email:
Property Owner:
Lot Address:
Name of Park:
Phone: / l 3 ?-3 7/§
r "1 .44 -A /7 -i--
Parcel: 0-1 1c,oo-L 000 bl PIN: 1(.ocsL- Z(~-SyZ3.000
ZSW DW TW (Size l -A x 2 # Bedrooms:y~ Year: 199 ?3
Power Company: Qa~s~2~sS f=r►tn (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 a
is co
DO NOT SIGN BELOW =FOR OFFICE USE ONLY
Authorization of Existing System
11-3-16
gnature of Environmental H ecialist Date
E-Healih~For Mobile Home Park
1 of 1
06/10