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ETApplication # 11 52 7 75-z Harnett County Central Permitting PO Box 65 Lillington, NC 27546 910 893-7525 Fax 910-893-2793 www harnett org/permits Applicant Name Address Application for Existing Septic Tank in a Mobile Home Park _ ~Ld;~ Date /0 -4 7 le{'L ~vv Telephone 9C © K ~5 / ( z (a Owner S Phone Property / J Lot Address 7-9 dG Z&9- N Name of Park a(D Lot Number t-la " h Parcel t ds2 d~ d PIN SW DW TW (Sizex } # Bedrooms_ Year r9~9 Power Company (For Progress Energy we need the premise number) Specific Directions to Job from Ldimaton L)d „.F. e V At/ , ,cF L I 7 ~ There is a $100 00 charge for this ii or If certification Is fsoprovtded anfththe ls Intended use of the septic system changes, application You signature below certifies that all above inP07ation is Corr ct Signature of owner or authorized agent DO NOT SIGN BELOW - FOR OFFICE USE ONLY Authorization of Existing System / Date 4~nature of Environmental Health Specialist