ETApplication # (�', W -t ✓��; )
Harnett County Central Permitting 1`g
PO Box 65 Liilington, NC 27546 f{ n
910-893-7525 Fax 910-893-2793
www.harnett.org/permfts o�1
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: M ruud Let -e7— Date: 4 —Z3 - /
Address:
Telephone
Property Owner: ul I f e,� Phone:
Lot Address: /5-1
Name of Park: {i 11LL r n {ti! F{ (' Lot Number: 15-f � T �jtu � 4
ParcelPIN: �S4q- - t1S Z •Ot)O
_SW —DW _TW (Size x�) #Bedrooms Year
Power Company:__ l it fL (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
1 / 4i-4 P- yVf j Ocala✓ lien aAc Pg -risl•f- on 'tNt( e�
1 hCv v -e ri's tir an .11 T .ID,r.1,
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
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of �Existing System
y - z69 --i 8
I nature of Environmental Health Specialist Date
SEPTIC