ETApplication # 'b iS
Harnett County Central Permitting L L�V)
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793 �ba-
www.harnett.org/permits ' 1 ,�
Application for Existing Septic Tank in l�
Applicant Name: F—Ova'i c\p G
Address:
Telephonc
a Mobile Home Park
rciw nat'- fir' - 17-
Property Own
Lot Address:
Name of Park: �—
Parc
Lot Number:
PIN: �q D. S -6'S11) �CY7V')
SW _DW TW (Size .�x%6 ) # Bedrooms �_ Year_J'f�Q
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
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.
Yo Ig nature below certifies that all above i formation is o rect.
nature of owner or authorized agent: d 'y
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
of Environmental Health Specialist
SEPTIC
Date