ETApplication# 11_5DDqZUI5
Harnett County Central Permitting
PO Box 85 Lillington, NC 27548
910-893-7525 Fax 910-893-2793 V01116
www.hameft.org/permiis
Application for Existing Septic System Inspection in a Mobile Home Park
Applicant Name: 4'1 a.�I%i T
e ,U L) i .S Date: 1V1d y/ -;UJ1
Address:
Telephone:
Property Owner: A
Lot Address: F5
✓d le
C L.c> b Lease) LL C
-a5-7-
Name of Park: LJ1 dW60.vt ( ; r et lit )V.H Lot Number:
Parcel: Nos35 wo so PIN:_ 0514.59-164q.=
SSW _DW _TW (Size _x IOC 1 # Bedrooms _.'2 Year 19 7 7
Power Company_JD0W__Z\W2X EMC (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
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 i rrect.
Signature of owner or authorized agent: �A 1a. L
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environments ealth Specialist Dalb
\b d S
2108