ETApplication # R- J IJM; E�
Harnett County Central Permitting
10 Box 75 Lillington, NC 3.279 (�2ti1Jq
910-893-7525 Fax 910-893.2793 I
www.hamett.org/permits W
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: a n r� "— Date: / 12, e-
>/1
Address: _1 z1 45 NC r7 P,>ro.j N C 750 5 -
Telephone: -(110) 364- ?_96 9
Property Owner: Eck ala i 5 .-Av1,4joq pAVA�, ,L C
Lot Address: 4--l- i- o .r A 4 N C*
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Name of Park: 6 R l e' S Lan k'Vifl Lot Number: :) '7
Parcel: `ZQsil Nb, PIN: gS'1122'-7Uct-7•000
1L/_SW _DW _TW (Size_.x? b 1 # Bedrooms Year f
Power Company: Dv K t g n r r: j (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
Ta.k�
1y%�54'Vjoy N C ato - I5 rrlits
_:i? —� t S o Y� he { e f 4
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: \
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
�h Authorization of Existing System
Signature of Environmental Health Specialist Date
SEPTIC
4/06