ETApplicant
Address:
Application # 17 J Q Q 4 2` iq J
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Property Owner:
Lot Address:
Name of Park:
Parcel:. PIN:
4//SW _DW TW (Size �x 7D 1 #Bedrooms Year Zoo
LL
Power Company: wt`C!`q��1�`ifn C. (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
W
go lmif>r Trn r
There is a $100.00 charge for this service. Th
intended use of the septic system changes,
application.
You signature below certifies that all
Signature of owner or authorized agent:
SEPTIC
FRIN
h4-Cn4-t> s Our F;r5 o Or, hZa
s certification is subject to revocation if the `5 T-
or if false Information Is provided on this
is correct.
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Qc'v I
tel Health Specialist ate
4/08
7
S