ETApplication #
IL2-1F',-'~
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft,org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: biA-~ Gil Date:
Address: y lb U s ct } l
Telephone: (91 6 9J77 r -2,-Z,96
Property Owner: Q ` t lr ttm 4.. A^4- Phone: 010 ~ o L 2•
Lot Address: 17 r. ~ Lo-C -
Name of Park: 1.. M l~ L
of Number: V 1
Parcel: PIN:
_ZSW DW TW (Size 114 x -1-0J ) # Bedrooms Year 1 4
Power Company: I'e (Far Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
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 .owner or authorized agent:
DO ELOW - FOR OFFICE USE ONLY
h i of Existing System
Signature of Environmental Health Spe st Date
SEPTIC
4i 08