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Application # (0-50b-2-q-755
Harnett County Central Permitting
PO Box 65 Ldlington, NC 27546
910-893-7525 Fax 910-893-2793
www harnett org/permits
Application for Existing Septic Tank in a Mobile
Applicant Name ~,,,/,,o~,
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Address kiS,P r 7 v n_ .
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Telephone_~t19 - .42a _
Property Owner
Lot Address Phone
4 +T'o c,c ~ ~ ,
Name of Park
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Parcel Lot Number
PIN t}y
--K--SW DW TW (Size I x (n Q-
# Bedrooms __*3
Power Company
(For Progress Energy we n
S ecfic Directions to Inn from Ldisnatnn
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1 1
Park
'7 NO
Co
4 - /3 0 000
:d the premise number)
There Is a $100 00 charge for this service This certification is subJec 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
R l
of Environmental Health Specialist
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SEPTIC T~jy•1
4/08