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1-5`•1f
Application # 11.5"00 9 - qq!D
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Applicant
Address-
Application for Existing Septic Tank in a Mobile Home Park
1~l~Sl. Date: ad,
Xv
Telephone: / Email:
Property Owner: Phane:- ?.o tS~f/
tin- Lot Address:
Name of Park: Lot Number:
PIN:_ip 1_/ 'L,0 vL
DW TW
(Size- ----x ► # Bedrooms: Year. 6
Power Company: (For Progress Energy we need the premse number.)
Specific Directions to Job from Lil inatan: 1 .0 .
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 ' rm n is c rec
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
of Environmental
Specialist
Date
C'o F A-P