ET~ Application it 23.
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.hamett.org/permits -
Applicant
Address:
Telephone: -210-- ~pl~ J . 45-D y/l1 " J~tx - Z"570
Property Owner: .,T'1r1 /rtV Phone:
Lot Address: IZ69
Name of Park: Sri n 0 Lot Number "
Parcel: PIN:
SW DW TW (Size x } # Bedrooms Year
''e Power Company: (For Progress Energy we need the premise number.)
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 ti I rr t.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
if Envir ental Health Specialist Date
SEPTIC
4100
Application for Existing Septic Tank In a Mobile Home Park ^