ETApplicant
Address:
Telephon(
Application # ITSW42� (-00
Harnett County Central Permitting
PO Sox 65 Lillington. NC 27546
910-893-7525 Fax 910-893-2793
www.hamett-org/permits
Application for Existing Septic Tank In a Mobile Home Park
Property Owner:
Lot Address: /
Name of Park: �1 L1(d��f''*� l' Lot NurFiber: /
Parcel. %04 o�0g PIN: -2 .000
Parcel:.
___TW (Size'-Lx-'00� # Bedrooms _ __ Year..2-007
Power Company &.,& / (For Progress Energy we need the premise number.)
0
tare Is a $100.
00 charge for this service. This certification is subject to revocation it 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. —�
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of E'' ting System
Si lure of Environmental Health Specialist Date
SEPTIC
a/p8�
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