ETApplicant
Address:
Telephone
Property Owner:
Lot Address:
Application # 11 5wy 1 � Q V
Harnett County Central Permitting gv�
PO Box 65 Lillington, NC 27546 ( o�
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Lot Number:
M
PIN: q `Wi -I w, a ISCSo
SW _DW _TW (Size
.r#F�Bi3edrrooms Year Zyy,-
Power Compan/!,gsr
ogress Energy
we need the premise number.)
Specific Directions to .. from Lillington:
6000mew
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
Signature of owner or authorized agent:
O NOT SIGN BELOW - FOR OFFf6E USE ONLY
Authorization of Existing System
-7lY l
Signature of Environments ealth Specialist D to
SEPTIC
4/08