ETApplication # I 4 a 35 l
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: kA xuvesTyAr- j ; s Date: -tet- i -i
Address: —x_93 .ns yzt N i-z,..,_=N670A1 ziru
Telephone: 9 io _ 903- i9 -i
Property Owner:
asti
Phone:
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Lot Address:
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Name of Park: -r
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Lot Number:
Parcel: 1 z o Lz
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5'1 - 9 q
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_TW (Size 16 x —UG )
# Bedrooms 3
Year zo Il
Power Company:
{For Progress Energy we need the premise number.}
Specific Directions to Job from Lillington;
1 AVE
421 N
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on,
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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: __�or�y� %_" 21�
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
-
Authorization of Existing System
i
of Environments Ith Specialist to
SEPTIC 4/08
26 \�
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