ETApplicant Name:
Address:
Telephon<
Application# 1�5�VWV(jgS
Harnett County Central Permitting _ b�ouuQ)
PO Box 65 Lillington, NC 27546 ,1 I
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Property Owner: Phone:
Lot Address:
Name of Park: J4,U4 .&/f Lot Number: OAK^ 6
Parcel: PIN:946y-?7-9702-/X�d d+�
SW DW TW (Size ��
—xJ # Bedrooms 3 Year
o�� _
Power Company: %Yogi, (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 information is correct.
Signature of owner or authorized agent:.V , ., [ l,/.1i,4.0 f„-�.
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Signature of
Authorization of Existing System
Health Specialist
a) ,,
Date