ETApplication # l D' JI N vow
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 2�%� 0 fiw✓40
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for
Existing Septic Tank in a Mobile Home Park
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Applicant Name: e, I D /) Ci . Lip, noro • 2.9-n - LR
Address:
Telephone: bL+U - 3 b l -
Property Owner: tJc {,artcL �(,ISgI (,tom Phone:st+a 3b7 5q-':°
Lot Address: -lLq N. Pe�ac{. S{-r.�{ �rzv+ct 1,a,kQ
Name of Park: �S� l r5O►� G'rot'jL. Lot Number:
Parcel: d St� �(0�7 PIN: (in 65 -Sb- gJo3O-DD6
CC�SW DW _TW (Size 2.�d x lob) #Bedrooms Year Z )tb
Power CompanySMA 14W jj fAG (For Progress Energy we need the premise number.)
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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 corre.84��
Signature of owner or authorized agent
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
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Signature of Environmental Health Specialist D to
SEPTIC
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