ETApplication # 1 9 S C04 a N D
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: bSvn TWVESTM+c-NiS Date: 9 -'Li -r7
Address: 3183 ins Nz.i m. L3. "=tv4ToA/ A3G z e su L
Telephone: y to - 303 19 4.7
Property Owner: anti IrwhJcSTVNE'NTS Phone: 910. 303.t51.'1
Lot Address: 31 LHA21' De. e Lz LLZ N4T'JAi ; NL_ Z -7s4 4P
Name of Park: -rNe Hp-'^oLAe_ Lot Number:
Parcel: 130 txZc oo NS o 3 PIN: Di, 3o - 5'7 - 9 Scti4
W DW _TW (Size I (e x t. L ) # Bedrooms 3 Year 2-0 11
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
1 A1cC UZI W. 7-VWAtL% 5-RNFoRD . 1 Hir PF 9-V_
wS LI. V%F om THE (-2G Ha ApPRoxa rynpa Uy i4 M., I es
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 it 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-t4ealth Specialist
SEPTIC
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