ETApplicant
Address:
Application # J-]
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-693-7525 Fax 910-893-2793
www.harnett.org/permhs
Application for Existing Septic Tank in a Mobile Home Park
Telephone: 41)—`-2Z Ctc( (Zyean1-&) b,—C[,U-3() Sr-G-j2cj
Property Owner: --,YAy1iy-AO'E ATULlf , Phone: 73- rYy5'-
Lot Address: nn (-AMiI& Li.i
Name of Park: Lot Number:
Parcel: 6631 PIN: 006
�SW `DW TW (Sizex�� # Bedrooms 3 Year 2066
Power Company:(For Progress Energy we need the premise number.)
S ecific Directions to Job from Lillin ton:
�1� •eLL��lt� of �-- R�:I�11f
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 1 fmation is correct.
Signature of owner or authorized agent: �—d'C
IIEL—
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environments alth Specialist date
SEPTIC
4108