ETApplication #. ITMM %77
Harnett County Central Permitting �\
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893 27930
www.harnett.org/permits
r Existing Septic Tank In a Mobile Home Park fel
Applicant Name: L 1W -Date " )-I)- r -ZVI
Address: �7� C L3 �
Telephone: ` / - 6
Property Owner: I� Id (,egSQI �((' Phone: (Q -] )q(p7
Lot Address: 50 b. n v, '>Ai?G;n
Name of Park: Fkf)Oie- SIC6 (.(PAIL Lot Number:
Parcel: DID -ly D3(P'1 PIN: CS I S- Sd' 4 fOjy. w
VSW _DW _TW (Size -Lq-xD. 1) # Bedrooms 3 Year
Power Company: 0 P 1QV T�PM.(For Progress Energy we need the premise number.)
There is a $100.00 charge for this service. This certification is pubject to revocation if the
Intended use of the septic system changes, or if false inf ma ion is provided on this
application.
You signature below certifies that all above infofnation is
Signature of owner or authorized
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
1'\ \\uthorization of Existing System
Signature of Environmental'Health Specialist Date
SEPTIC
4/08
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