ETLp(.Q JIV Application #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.hameti.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: C N Com- M 14 P b (fir IV �nn L 1 L Date:
Address: �f G o S Dflau LF Y r S 4'e 3 01
Telephone: (9 / D7 5 Z ¢ - 0 13 .
Property Owner: —C -&t6=
Lot Address: t 5 2- 01
Name of Park: Old Lot Number: / 5
Parcel; PIN: 2
1 SW _DW _TW (Size x_, # Bedrooms l Year 1 7 9
Power Company: (For Progress Energy we need 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 it false information Is provided on this
application.
You signature below certifies that all above information is correct.
Signature of owner or authorized agent: -/.
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
of Environme ealth Specialist ate
SEPTIC 4108, \//bj1Pj