ETApplication# 1%7560l-41sg7
Harnett County Central Permitting 1
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793C(jboCo�
www.harnett.org/permits ()la! 1�7
Application for ExistingSeptic Tank in a Mobile Home Park
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Applicant Name: "o �,- i A,, Date: le, 9 c&o I �
Address:
Telephone: ') 15 -'4oig 93;k'.>
Property Owner: `a C'rc'WN Phone: qt9 Q?5 O
Lot Address: IIoS
Name of Park:QPkvu M a -i �P Lot Number: ILS
Parcel: 62,(S-2C.O n10 l PIN: -S-72 -( -S35 3. 620
�- SW _DW TW (Size H x(P_) # Bedrooms )— Year /� iv
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinoton:
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: '�Iea 4zam4L
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of EnvironmentaTi4aqlth Specialist Date
SEPTIC 4/08 C\
10