ETApplication # 1:1 _ x 4014.5-
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits ` j
Application for Existing Septic Tank in a Mobile Home Par SC 41f6
Applicant Name: '` I U, C Date:
Address: dig l &--non Aoaci _ no mer Nr- Q7�Ja
Telephone: qf�1-(�39 �iU3a
Property Owner: .he k)prQh LL [xl+¢i , r1,C5 Phone: 9 (a - 4a l - l l o 03
Lot Address:
Name of Park:
Parcel:
Lot Number:
ve� SW DW TW (Size J� _x�t2) # Bedrooms _�_ Year I q gq
Power Company: Oen+ r(i ( r I,CC` il- iG (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillin tcLon:
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: -t )a4X.1y z )
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
Signatu a of Environ m Health Specialist bate
SEPTIC
4/08