DOCUMENTS / RECEIPT lD.' a ` krl
Application # fl5Obt-4-iaL04
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793 SCANNED,
www.harnettorg/permits
OCT 3
Application for Existing Septic Tank in a Mobile Home Park 11D17
Applicant Name: Iat S S' , Yn C L°0 y Date: /0 ' a 7 -I 7
Address: 1(07 ( -y` PenLUa y 1riie-
Telephone: 336 — 49/ - 57
Property Owner: Phu. 11 i S M t-Ceti Phone: 33 40 $9/- 7 357
Lot Address: SI " I4 e -die-A-son De. , A-None' A C- ..275O(
Name of Park: Black RiJu Qua MIP Lot Number: / a"
Parcel: 04 C7.S7 14 up-Ay PIN: CW-T(4 ^o1C1r - a5 (D Or '(XoO
/ %�'r
VSW DW TW (Size 114 x (a(o ) Bedrooms Year /
e Po
Power Company: �u K (For Progress Energy we need the premise number.)
Specific Directions toJob from SLiilllinaton:
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(s0 .5OC.J ftJ j-FN75 a /O - tuAdr.
0141-0 I4w t/ ,55 G-o lade —1-cc-
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w-P ST PQr, 6 SIS C of v-a6 1(20ae IN4P I S a IBS
ot^ ie r 19 Neal &S& t'r uej
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. yy,
Signature of owner or authorized agent: °�v t
; 4-111 C a
DO NOT SIGN BELOW_- FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
SEPTIC 4/08