ET�--, lam 1 Application # s56D43 n'`/
Harnett County Central Permitting
PO Box 65 Llllington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/parmks
Applicant
Address:
Application for Existing Septic Tank in a Mobile Home Park
Telephone: (!710-)52- f- - 0 1-3 6
Property Owner:
Lot Address: /
: Vo 4 - 5-3 9 - 4295
Name of Park: Z n l c4K / n 9- Lot Number: 4--23
Parcel: PIN:
V SW !DW _TW (Size x .) # Bedrooms _ Year
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
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: a'4'W Z
DO NOT SIGN BELOW -FOR OFFICE USE ONLY
Authorization of Existing System
5 rd t%
Signature of Environmentallipalth Specialist Date
SEPTIC
4/08 Q
W
x.25