ETApplication #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www. ha rn ett. o rg/perm its
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: ~t -U -2 C /c
Address:
Telephone:,/
Property Owner: Phone:.fW?-g LLZ
Lot Address:, e-"-
Name of Park; I 00 Lot Number:
Parce - / PIN:
SW DW TW (Size x # Bedrooms Year-J:LIL
Power Company:: ~„'.Pa~zL. For Progress Energy we need the premise number.)
Specific Directions to Job from Liilinaton:
You signature below certifies that all above information is correct.
-
Signature of owner or authorized agent: ZZZ<> ZZ4 ~
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
i k- 4,- 2
Signature of Environmental Health Specialist Date
Pa, t PC,
-,5
SEPTIC
3 030
A/0B
There is a 00.0 charge for this sere ce. This certificatl n is subject to revocation if the
Intended use of the septic system changes, or If false Information Is provided on this
application.