DOCUMENTS U )cW ' 1 V Application # I .5(2043 0 D '7
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnettorg/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: t-o /e S �-a I .tJ 1'i LLC Date: `- /16 /1 SZ
Address: J2- I 45 NC a-7. 13roac/wn7, v..fe 2- 75.0_5
Telephone: ( cy; c)5 2 41 — O 13 L.
Property Owner: jet, ' LaHi; ruitr? LtLPhone: 5704 - S37 - 4295
Lot Address: / Vet//1 Fu)/c Pr I ✓r •
Name of Park: i rz)/e i S 1.0 "- eh la" Lot Number + 3
Parcel: PIN:
v SW DW TW (Size x ) # Bedrooms 3 Year I", 9,P
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
rr.Ce ,41/9/14-4.17 a7 IA-) fowo-tJs ,da el"/y, r to/C o<
.Le,( o N t/o n AY -1 /nr Vl ct_ ry t r Gh 12�t (
-6�t�Ie DY . l
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: (9.-4-L6 Z " C
DO NOT SIGN BELOW- FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
SEPTIC 4/08
HARNETT COUNTY CASH RECEIPTS
*** CUSTOMER RECEIPT mm+
Uper: JBROCK Type: CP Drawer: 1
Date: 4/26/18 52 Receipt no: 332856
Year Number Amount
2818 50043884
181 BALD EAGLE DR
BROADWAY, NC 27505
B4 BP - ENV HEALTH FEES$100.BB
EXT TANK
ANNA MUNROE
Fender detail 108.88
CP CREDIT CARD $$100.00
Total tendered $100.00
Total payment
Trans date: 4/26/18 Time: 15:51:19
am THANK YOU FOR YOUR PAYMENT **