ETApplication #16
Harnett County Central Permitting
PO Box 65 Liilington, NC 27546
910-893-7525 Fax 910-893-2793a t l
51
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
.
Applicant Name; Date:
.
Address: l t I tL. Yk 4 IS'4 L
Telephone: tf'
Phone: /0-
Property Owner.
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Lot Address: /,'pVq
Name of Park:. Lot Number: -1`I
PIN. 5t°tt.i o
Parcel: loo```p c'"'
-.KSW dW `C'W (Size j ___.x~ ) # Bedrooms Year c
Power Company: (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:
00 NOT SIGN BELOW FOR OFFICE USE ONLY
Authorization of Existing System J-4164VII
Signature of Environmental Health Specialist Date
Ere, ru a..
SEPTIC
4/08
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