ETApplication # � �500q 361(V
Harnett County Central Permitting C `�
PO Box 65 Lillington, NC 27546 lS `
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
-Application for Existing Septic Tank in a Mobile Home Park -
Applicant Name: 130-13 crib 7 & �#1>919N Date: / - )- —
Address: X % 7
RAF
Z 7'5--V4
Telephone: /9/i F-0- 3
Property Owner: ?�S7'Di✓ /3/9,1;,c%rrd Phone: -
Lot Address: fW 17�D 0_91ey c7r fc�U.y,9�. cJ�9r- r� ,tlG Z 2S2 �o
Name of Park: 1271 %/ e 12fe /_ L);'119 5 e— Lot Number: /-
Parcel: S ` S PIN:�o�S- 1U5'(d OL OUG
_SW _DW _TW (Size x_4C # Bedrooms S Year W9,
Power Company;
Specific Directions to Job from Lillington:
Progress Energy we need the premise number.)
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 aboveinforrnation is correct.
Signature of owner or authorized
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
2'� i
of Environmental Health
SEPTIC
of E
Date
XC
4/08