DOCUMENTS Application # f . ]tx ;3 3
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: OSNrUJESTNAc-V s Date: 9-1-t- n
Address: 3193 1kS 4z1 N. N 6s70A,
Telephone: 4 to - 3o3- iA 4-i
Property Owner: C.5 LA =rJJ3$T✓Y)EN75 Phone: 910. 303 . 19tri
Lot Address: f i-LAArt DQ., 1 SLLt NLTJN . NJ(. 227S%
Name of Park: -r He I-1o'hpL44. Lot Number:
Parcel: 130 (Azo Co 4S o 3 PIN: Cu,30 - 5.7 - 9 $9y
✓SW DW TW (Size I to x tP 6 ) # Bedrooms 3 Year to it
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillindton:
TAKE NZI N- To wRQOS S14.v FORD . THt PARK
Jt LL y3C ON THE 9-T.GHT (,pPRo-xn1 ATE(-" q vn. lcf.
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
SEPTIC 4108