ETApplication # 19 S 4;(;4
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: t>5 -k rtiv06rw,E•.,;t _Date: ci-7.1-1'1
Address: 3 t 93 vs 4iZt AdL 1 LLQ"&-rCAl Nc z-+ru t.
r
Telephone: ci l0 303.15 tt-t
Property Owner: Phone: 9 0-3 Ieit."1
Lot Address: 4 i uR21 D1?. Ls LL2 n�G ren! '�� Z'7Sy 10
Name of Park: -rhc- Mo -1 ELAt..t Lot Number:
Parcel: 130 Lo.Zc QO4Sa 3 PIN: D1.30 - 57- 9'8g4
W _DW �TW (Size _L 6 x U 6 # Bedrooms _ I Year zo 17
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillin=:
i RkC 42-t U TowARhS 5A'VFOR b 1 11t PARK
w= LL a;= op- t HE MG Err APPRoxS rInANTEt_r' 4 .+.. les.
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: T
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
a al 1
ienta ealth Specialist Clate
SEPTIC 4108
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