ETp Jan a'-) Application # 1'-) SCi�) t4 Z2 UL -LS
Harnett County Central Permitting
PO Box 65 Liliington, NC 27546
910-893-7525 Fax 910-893-2793
www.hamett.org/permits SCANNED
Application for Existing Septic Tank in a Mobile Home Park OCT 3 1 X017
Applicant Name
Address:
Telephone:
Property Owner:
Lot Address:
/ 1 1, S ' ' , N 0 to 1'/ Date:
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t Phone: -5'3 & - "/- 7 -YS %
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Name of Park: 13 f a CV—
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Mlf3 Lot Number: /
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PIN: W-114 ,
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p )4' x %(9 I) # Bedrooms 3 _ Year / q qf'
Power Company: Yw �: L° f 0 WG P` tFor Progress E ergyy we need the premise number.)
Specific Directions to Job from Lillinoton:
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IS .ern" 1eS
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:
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DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
.Signature of Environmental Health Specialist Date
L/
SEPTIC