ETApplicant
Address:
Telephonc
Application # 1 f5
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
Propeny_Owner:`,No- �txn �F,� >r Phone: t zi - &<-9- '3-3 7s.
Lot Address: -4 4 K" c. r 7-34 mei /!„ � .� '?V
Name of Park: CoP-e 't Ga.., J-" rsr S Lot Number: 2-
Parcel: 0 2-1 5 2 co 00 H -F PIN: 15-'P- - "jLV- 9 2-) 3
SW _DW _TW {Size ly x_ _) # Bedrooms Year
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillincdon:
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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
Signature of owner or authorized
SEPTIC
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
o3�c%I dor
Signature of Environmental Health Specialist Date
3.
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