ETApplication #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
Application for Existing Septic System Inspection in a Mobile Home Park
?s Date:
en5k-
Applicant Name: e:~ml
Address:
eir 22~f
Telephone: 2 -.2 Z 5`-/
Property Owner: •r~~.~rv y ~Iie~c~- Phone 91~r 4(2Z - ZZ5'"/
Lot Address: 7!2 Xir~a
Name of Park: 5- g Y4~ /11 Lot Number: !y
Parcel- d ? p ry 00 ~Z) PIN: (XAea - 74-9,''60-0(X
_Z'- SW DW TW (Size 1 x94:~' } # Bedrooms 3 Year 19 q--
Power Company_ re-~5 ~~A ~ (For Progress Energy we need the premise number.)
- -
/07, fps
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
is
Signature of owner or authorized agent:
DO NOT SIGN
- FOR OFFICE USE ONLY
Authori tion of Existing System
Si tune of Environme Health Specialist Date
2108