ETApplication # 0 - 5l' y- r U `_\ L -
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/perm its
Application for Existing SeptiriTank in a Mobile Home Park
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Applicant Name: fi ry :,.t- Date: J
Address: p a . SO k 2lo gr.ei' nC 7 ySa
Telephone: y Q(a X
Property Owner:
Name of Park:
—DW _TW (Size -&-x 3 0 )
Year t7/„Z-
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 into mation is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
K -.o -A-4 4-1—f7
Health Specialist Date
SEPTIC