ETApplication#
l Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-693-2793
www.harnett.org/permils
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: X Z F7% TS Date: / - -le
Address:
Telephone:
Property Owner: AOZ1�l '&q_1 rs Phone:
Lot Address: lD / M&—Z-0"q 5%-, /i/L
Name of Park: fp�y.ZD'ec VJLz &� E Lot Number:. _5�1_6
Parcel:_t% DUU L D014 0�- PIN: CMUeZ-i( "5l982'0Q'--)
_SW I"DW TW (Size a exp) # Bedrooms 3 Year
Power Company: , I C�� (For 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 above information is correct.
Signature of owner or authorized agent:�llG2
SEPTIC
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
-2 �� g /-12,-/8
of Environmental Health Specialist Date
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