ETj Hamett County Central Penr
PO Box 65 Lillington, NC 27
910-893-7525 Fax 910-B93
www. harnen. org/permfts
} Pplicant Name:
Address: _ r-�
Telephone: Oi
Property Owner:
Lot Address:
Application for Existing Septic Tank In a Mobile Hoine park
Name of Park: S
Lot Number,fj
Parcel (�) h -Z H
�SW,C--�.�: 13 J6
PIN: r2�i7��— _ I�, pZXj
`TW (Size FEZ) # Bedrooms _
Power Company,��')G Year i ,
(For Progress Energy vr need the premise number.)
5 I is irections o f om i do ;
There is a $100,00 charge for this service. This cettmeation is subject to revocation if the
Intended use of the septic system ohan
application. goal or If 18188 information is Provided on this
You signature below certifies that all above information is correct,
Signature of owner or authorized agent:
DO NOT SIGN BELOW --FOR OFFICE USE ONLY
\Authorizatjoj-, of Existing System
S'PTIC \�
4/09 1 '\C