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� D, an l t Application # _ I'I Jt�Cq an11L4
Harnett County Central Permitting
PO Box 65 Liliington, NC 27546
910-893-7525 Fax 910-893-2793
www.hamett.org/permits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: /1 ikS
Address:
Telephone
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Property Owner:
P11A., /1 i < & , ni (- (.yy(
Phone: 336 --J491-
73S7
Lot Address:
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Name of Park: 8 f a Ck k igc-r Vu ft M#P Lot Number: 3
Parol: Oy OLO-N r3o4q PIN: L-lOiy - aLP—P5Loq-Od6
SW DW _TW (Size !Af 1 x %o�) # Bedrooms 3 Year
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POWer Company: (For Progress Energy we need the premise number)
Specific Directions to Job from Lillinaton:
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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: 40A4e'
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
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ignature of nvironmental Health Specialist Date
4106
SEPTIC
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