ET RApplicant
Address:
Application # G—Sto7t2Sp 9
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
Telephone: y'/ T 7, 01 7: -Y/
Property Owner: t'[en7,-t1f X41111S Phone: )'[0,F5 -P7 70,90
Lot Address: dpi%
Name of Park: L�ya- �-"Vt Lot Number:
Jt^
Parcel- PIN:
JZSW _DW �TW (Size Ax -10) # Bedrooms Year jq_J3
Power Company A�Aw (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington
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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 inform0on is
Signature of owner or authorized agent:
DO NOT
of
SiowkA st"
SNOLbwt VtAtL
SEPTIC
— FOR OFFICE USE ONLY
of Eo,;;tirtg System
Health Specialist
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