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Application #
Applicant Name:
Harnett County Central Permitting CANNED
PO Box 65 LiNington, NC 27546 23`1C
910-893-7525 Fax 910-893-2793 :)A
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
/4
Address: `25 3e x , 3S U due Oak& bC- 27 sa-4
Telephone: ! Iq - V G- 3`~ 190
Property Owner: Phone: b ' 2 7 s2'
Lot Address: V"Vb JL
Name of Park: I'ns--, Lot Number:
Parcel: D`11 tv 1 o 010 'I PIN: 1 t~(o 5~-~41y
SW DW TW (Size x 90) # Bedrooms_ Year qt~~
Power Company: Zjc) r . S X 'k 2' (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 information is correct.
4 Signature of owner or authorized agent:
SEPTIC
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
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re of Environmental Health Specialist Date
4108
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