ETApplicant Name:
Address: rr,
Telephone: Ot
Application `iL4 D
Harnett County Central Perm Ing
PO Box 65 Lfllington, NC 27*6
910-893-7525 Fax 910-893.2793
www. hernett.orgipermlis
Application for Existing Septic Tank in a Mobile Home park
Property Owner:
lot Address: L'�""`--` ;how'
--�
iName of Park: Sjj� � -4
Parcel: , L Lot Number. p
SW ✓DW PIN: �UqI .ply
_TW (SizeZLx-W-} #Bedrooms_ 3> Year
Power Company�tw G
(For Progress Energy we need the premise number.)
Soecific Di- ;^z io Job frnm Lil_ ling -ton:
intenThere is s $100.00 charge for this service. This certification Is sub)ect to revocation if the
ded use of the septic system changes, or If false Information is provided on this
application.
You signature below certifies that all above information is oorredt.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmerta aaith Specialist tS: 1
ate
SEPTIC n
4/08 �1 )