ETApplication # n 50 g 1� 2 q
Harnett County Central Permitting
Box 5 Lillington, NC 27546
91010 -893-77525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name:��p L`r7 / Date: S ; /
Address: / C// j(�j % F� //,1;
Telephone: 9 9
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Property Owner:
LD
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Phone: 9/i
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Lot Address: -29' Y-
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Name o� Park: �� 6�� Lot Number: n
Parcel: 1 U � 7 N (,J PIN -C(,O1 — ni ((-( — i X/A-6IA `A
✓SW _DW _TW (Size �x�) # Bedrooms _ 3 Year `i"
Power Company: UKP �(For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
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:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization
/of'Existing ystem
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<--Z`t-17
of Environmental Health Special st Date