ETApplication # 1_75w1 2- 1, d V
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name:
Address:
Telephone: q ( y
m ES w %/7 N
yq3
Property Owner: AAL �A"" �C- Phone:
Lot Address: 6
l H/� N
Name of Park: 'AND c PSV N CQFtFk (K N 'Pumber:
Parce • Q)OS,�,S 61n 3() PIN: 6S Iy— ; — 35L/q,� )
SW DW TW (Size J_y_x_S�PJ # Bedrooms __ Year Z
Power Company: (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 infor ation is correct.
Signature of owner or authorized agent: AA C
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
\Authorization of Existing System
Signature of Environmental Hea ecialist bate
06
SEPTIC 4/08