ETApplication #
Harnett County Central Permitting
PO Box 65 Edlington, NC 27546
910-893-7525 Fax 910-893-2793 SCAN
AV, NiC{
OCT 3
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: rO� (I t S S, rw C C°0 � f Date: / y -7 i
Address:
Telephone
Properly Owner:
Lot Address: 3l
-!/-7es7
Name of Park: S l a C k r, i jt -r 12 I .,ft MAO Lot Number: / -#—
Parcel: (J4 U014 IN-%AqT PIN: t710`7U —.SCh — LS
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_ DW TW (Size /4f x (P61 1 # Bedrooms Year _
�w Ke, Po we r s y p
Power Company: (For Progress Ener we need the remise number.
Specific Directions to Job from Liilington:
Co .bow A) J4Wy a ld - 'r1kA4A- c
e-) A4 -,D H -1-o V 55 .. G�r-v / w i l e x r,
hricv-c
m. (a -S
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.
,�_�y,
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
nature of Environmental Health
SEPTIC
Date
4/W