ETApplication # ! 1~~ 9 w0 3
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: _ 1A)0_ /If/- ko Date: I J
- ~ -
Address: P 0 rev U X 3FL4 r~6 J-4t, SC4 J,
Telephone: 9/§ " J & f - a ~6
Property Owner: SLlv_ ckr&l ' Sit- hur),soo Phone: kAP 7
Lot Address: r--M' S ti ~ar~ 2.
Name of Park: C_Qf'r~r yq Mr-~Ot, e_ } Lot Number:
Parcel: LA 0ac-1 Da l ff PIN: N.a~r~. - (gU 3q,00b
,-'SW DW TW (Size Iq x17,0) # Bedrooms 9 Year 2e
Power Company: (For Progress Energy we need the premise number.)
Soecific Directions to Job from Lillinaton:
~ ~j apt 1 ~(,v `L
10 1 a dzl! ; e L rvickE, Q. 2 j L'5
(-CJ 1)()1 U-" (nY1Qr k
C✓ 1~I~rJc / lbiye, ✓Il on
k4
_41e Cli IC 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 inform ion i corre t.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization =r"!
h___e~ Z ' Afi_7j re of Environmental ealth Specialist Date
SEPTIC
pi 4/08
Con,