ETApplicant
Address:
Telephone: '-I lq l' 1 S - $ a,~
Property Owner: QnbQ r'4 F-t4 1~h Phone: 0t 15 99 7- 3 y 31
Lot Address: ~ `-1 UA!4 C'-1- ~ a MIW tiL
Name of Park: _"CAUT ' ODOR C,i M R ? Lot Number:
Parcel: PIN:
VV DW TW (Size t x o) # Bedrooms _9l--_ Year
Power Company: G%n k G_IPr_~ r r (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
wAim U14,
%Ae t_
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 of owner or authorized agent: Ljln4o
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Application # O9 500 9,t99 tO
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Authorization of Existing System
Signature of Environm
Date
Specialist
SEPTIC
0aq yG-l
S
4/08
Application for Existing Septic Tank In a Mobile Home Park