ETApplicant
Address:
Application#X] l7 W "I l , ] b a-
Harnett County Central Permitting "l
PO Box 65 Lillington, NC 27546` V
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Exisfina Septic Tank in a Mobile Home Park
Telephone: NQ -,35/7- 3 He26
Property Owner: !✓C LanW Zea.se LLC- Phone: 5y0 -3.57-3y76
Lot Address: 70 Npena,/ej Aa LA Le
Name of Park:
Lot Number:
Parcel A) Ui� S D3 (.0 -7 PIN: 0515 - 50 - 9630.000
- -t/ SW _DW _TW (Size �x� # Bedrooms � Year 119.7.
Power Company: �x„'H. Qi qtr >r AC. (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillingjon:
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 informationits correct.
�
Signature of owner or authorized agent: k-'rr�lt. -
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmenta Ith Specialist Dale
SEPTIC
4/08