ETApplication # i0 5-00 Ot 5 Ap
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 System Inspection in a Mobile Home Park
Applicant Name: Date: /a -iw-zvio
Address: / 15 / 5 GIs he
Telephone: (9/eJ 93v n13y
Property Owner: PhoneC9/9 ~
Lot Address: ~e & G r,-,dA j ,1
Marne of Park: rr,c
A4k Lot Number: 42
Parcel: PIN:
V--/SW DW TW (Size 7c) x /G ) # Bedrooms S Year
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
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 informatioVs correct.
Signature of owner or authorized
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
to
ignature of Environmental Health Specialist Date
2/08
i~