DOCUMENTS u I j Application # I 575 OLLOk-�t I `7
6 Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.h arnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: / ea , t 0 Date: %A—Le/ — 204
Address:
Telephone: 9/o' - Tel' 51"o`av w A 0 (i , C n wl
Property Owner: 76'1 %X/g N Phone: y/o - � 'O -06,46
Lot Address: /a f -' d44- 36) 7 `'et/4 y 5 f
Name of Park: Ca q rr y k'/a 6,1,, 7f.W c ,t-Ts,/,,S, Lot Number: ar
Parcel: PIN:
G/SW DW TW (Size /(1 x 70 ) # Bedrooms Year
Power Company: L e'tt/'¢/ 54f(` (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinoton:
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.
V .
Signature of owner or authorized agent: " ./....,e/
DO NOT SIGN BELOW- FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
SEPTIC 4/08
HARNETT CRAW :ASH hEEIPTE
*** ciJSTO^ER
_RE
***
Ooer: 3BROCK 'vae rV Drawer: 1
Date: 6iO4/18 52 Receipt nu: 374087
Year Hooter Amount
2018 50044169
307 PATSY RD
CAMERON, NC 26326
B4 BP - ENV EE?'_"H FEES
5100.00
EXT TANK
BROWN & BROWN PRO
Tender detail
CK CHECK PAYMEN 1739 4500.00
Total tendered 4100.00
Total payment 4100.00
Trans date: 6/04/18 Time: 12:20:39
** THANK YOU FOR YOUR PAYMENT **