ETApplication # I I- RVI SS -7J
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
Applicant Name: (11�Q (t1 )G1Vi�J Date: a ��
Address:
Telephone:'��
Property Owner: &K0, M Phone a --2
Lot Address:
Name of Park: ea S I ALot Number: 12
Parcel: s boil 0 PIN: aSq]'<N_11Yn`1 .000
�SW _DW _TW (Size Ai x�QJ # Bedrooms Year INS
D3
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
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 abovmation is cor
Signature of owner or authorized agent: �J��\ 2��
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
Signature of EnvironmentalHed h SpecialistI D to
SEPTIC
\46
4/08