ETApplication!,, 4,54b 9
Harnett County Central Perm Ina
PO Box 65 1_111ington. NC 275j46
910 www.hem25 ett.org/permts
SCANNED
www.harnett.org/permits {IY
Application for Existing Septic Tank In a Mobile home park
Applicant Name;
Address:—Date: I'2 --?,7---1
—= ry i2�. NCz 3
Telephone: Di(r)_ 5�2z rho, 1 _If
Property Owner: 4,4k
Lot Address: l ilN &"�' ~'�'hons;
Name of Park:
_Lot Number:
arcei:
PIN: -,'5T -
SW 'D►M1l_1W (Size _x # Bedrooms
Power Company: G Year_q
(For Progress Energy we need the premise number.)
ecific Direc Ions t JobM Li lin n:
There is a 8100.00 charge for this service. This certification Is subject to revocation If the
irjtended use of the septic: syrstem changes, or If false Information is provided on this
application.
You signature below certifies that all above information is correct.
Signatu, a of owner or authorized agent:
i
DO NOT SIGN BELOW - FOR OFFICE LIVE ONLY
�Authorizatici; of Existing System
SEPTIC
ate
4/Oe