ETApplicant
Address:
Application #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793 �D�lll
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www.harnett.org/permits Llv
Application for Existing Septic Tank in a Mobile Home Park
Telephone: ZZ0 —98�A —./o//s
Property Owner: ,P�� o f is Phone. %/- , �
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LotAddress: iJ� sgr,4riy/q / 7r� ffhiEz ZC,— 3'�;'---
Name of Park: Lot Number: 3 0�
Parce: ���4�42 �[� 0' PIN:
_SW DW TW (Size _�_x2xj # Bedrooms _._ Year /f97
Power CompanYL. � (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 above information is correct.
Signature of owner or authorized agent:/ycl2
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of isting System
Signature of Environmental Health Specialist Date
SEPTIC
4/08