ETApplication # l 5-60 a(.,o q
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 dl.�
910-893-7525 Fax 910-893-2793
www.harnett.org/permits 0041-7 U(l/
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name:
Address:
Telephone: 9/U I J
Property Owner: , NC LanA Lease l Lt -L Phone: q/O .2$ 7- 3 Co ( 7
Lot Address: jsD SU.Iff S -h SVr;cr. /a re ; ,y� 9.-Zlsn
Name of Park: An Au 41) r K, 'b I -el-" ?g;Lot Number: 15n
7SW
:��(i_(5l/SZ� O PIN:
DW TW (Sizer) # Bedrooms Year I, q b
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington;
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: `k '
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
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Signature of Environmen Ith Specialist ate
SEPTIC
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