ETApplicant
Address:
Application # �D- 5/V"( `M
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park ()J►V�
Telephone: q Iii --7 75-g5sq
Property Owner:jj1(�jj
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�C Phone: q1Q--775-g5L)9
Lot Address: ('5 I�I"VIG
CharIcs
A\{ic,
Wmemry NG 2S5 'I(p
(,Lot # '
Name of Park:
Lot Number:
Parcel: Cggr-55—( 6L4f)a PIN: C1655-LDI-a116
SW _DW TW (Size1 ._��x '7Q # bedrooms off, Year IgOtO
Power Company CejYLI I E Ie&r1 L (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:��� �\
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist D to
SEPTIC It
4/08'
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