DOCUMENTS Application # t f_t -+
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: n5u ruJesmotatf Date:
Address: 3 t Ft3 NS 4Zt N. L2. U of i-Tos/ AJC- Zz r4 t.
Telephone: y to - 3o 3- Ic Li
Property Owner: c.5 IA r..l.lcnel, N-rs Phone: 9 to. 303 . Icilpi
Lot Address: 9.1 £ taA2T DR. i rLLr NcrcIJ . MC 2_7 5 ja
Name of Park: THE FlompLpLE Lot Number:
Parcel: 130 Lazo co 4c o 3 PIN: Du 3o - S7 - 9 S9y
✓SW_DW TW (Size I L x U 4 ) # Bedrooms 3 Year 2-01,
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
TAKE 421 N. T'o wpto$ SIQN'rotaL) . THC pA2K
wtLL- YSF oN T HE 8-2G 1-11" APPRoxa rtn ATE LP 4 n...l<
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: 7T Y .-L1
DO NOT SIGN BELOW- FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
SEPTIC
4/08