ETApplication # «-JII0I215
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: _m testi... ► pr.• Date: 10 -r ? -n
Address: 8)S ia.,. j; Q� BKkyt...r(ittic Try+s
Telephone: 4 ro Sol- r p) u
Property Owner: per _I Orr _. Phone: a , d Po
Lot Address: 98S �,.,rQJ 8�,,.,tr„ t,J,
Name of Park: ate"i amp/. A71fJ� Lot Number:
Parcel: 12094-T 0022 D4 PIN: ()S47-94- `. 474.00D
✓ SW !DW �TW (Size /!x 7u) # Bedrooms _;LYear / M7
Power Company S .� M 1?1� (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
(a lyrt: /t c 6r- 1/0 %w/Ce ♦ /ef 7`me, 7'4%,&,A4 ccs✓
a As a.y- / 4 1" i At s art -1k iQl Aa Lcno" ,ee /h &e
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: `I> t v1 -1,a: p P . 0,
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environ
R to
SEPTIC
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