ETApplication # I� Jam" L3
Harnett County Central Permitting `till( Ill
PO Box 65 Lillington, NC 27546 Cr
910-893-7525 Fax 910-893-2793
www.hamett.org/permits
Application for Existing Septic Tank In a Mobile Home Park
yC Applicant Name: `TCSL 1.1 ' 9w./ P q! 7 Date:
X Address: 41 Lo&Y A/e,yJ: Ara"IV-wY r✓G 2IS'0
�( Telephone:
0
Property Owner:
Lot Address:
Name of Park: kbYC W (obi U nVK-1-M tot Number:
Parcel: 1n �Q� PIN: D1�10" DS 7SDq.0 )Q
--%/ SW —DW _TW (Size �xtQ]) # Bedrooms_ Year
Power CompanIQ/'i- _(For Progress Energy we need the premise number.)
There is a S100.00 charge for this service. This certification is subject to revocation N 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 coir .
p( Signature of owner or authorized agent: j)�– —
DO NOT SIGN BELOW – FOR OFFICE USE ONLY
Authorization of Existing System
V�� CLn•� �o a
of Eng viron?Men eaith Specialist Da e
SEPTIC