ETApplication # l 7560(43 V
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 Cc �� Q �a % 56 S
910-893-7525 Fax 910-893-2793
www.harnett.org/permits LL Mall
r,Existing Septic Tank in a Mobile Home Park
Applicant
Address:
Telephone: -9 / y -
Property Ow
Lot Address:
Name of Park Lot Number:
Parcel: SJ� l51 g() PIN: [g- a7- q
SW _DW _TW (Si e -b�—x #Bedrooms Year d
Power Company: PSS (For Progress Energy we need the premise number.)
There is a $100.00 charge for this service. This certification is subject to revocation if the
intended use of the septic system changes, or if false information is provided on this
application. -
You signature below certifies that all above information is correct.
Signature of owner or authorized agent: U
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorizatio of Existing System
�r�", c6lo9laot$
Signature of Environmental Health Specialist Date
SEPTIC
4/08