DOCUMENTS Application # In.5�.Thgi 3C
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
Applicant Name: o5N rNvesTYnC-VTs Date: 4--7-)-
Address: 3 t B3 vs Het N. L2. r-4-1 ru&Toy✓ A l z-r ru
Telephone: 5 10 - S03- It; s,_1
Property Owner: o5tn Sti ESTYYnE/.iTS Phone: "l 10. 3D3 . 19ta
Lot Address: 4LI LuRRT D2.. LSLt_-cNCrn.J . "J 2 5
LI
Name of Park: -rNt mo.+.vt_wcE Lot Number:
Parcel: 130 Lao EoOso3 PIN: Dia3o - n - ' eqy
W_DW TW (Size I (e x U I ) # Bedrooms 3 Year '1011
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
1 AKE Ott nl. To wAt OS SIQNt•o&b . I HE Pfl .
w=LL Re oN HE 1Z2 1-r- APPRoxa ✓ ATFL" q .+.. kc.
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.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
4/08
SEPTIC