ETApplicant Name:
Address: 17 9
Application # __ 11 SD0'+C? D 1
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank In a Mobile Home Park
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Telephone: 9 ! q - 7,7L"7- I y3 8
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Property Owner: Crr-^ i Ya q e✓ Phone: 0/ J 9- 7 7 n - J L13
Lot Address: H.3 "- i- qtr
Name of Park: c P Lot Number: N3
Parcel:_ 134527 PIN:-11-5t)pO
% -SW DW _TW (Size ) x 7 Z) # Bedrooms -2 Year ! 9 7.S
Power Company:.; V k )' i'y*f (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillingtonl: J / I
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There is a $100.00 charge for this service. This certification is subject to revocation it 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 System
Signature of Environ ental Health Specialist ate
SEPTIC
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