ETApplication # amt 5
6C E~ Harnett County Central Permitting
awe PO Box 65 Lillington, NC 27546 '
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing
rl Septic System Inspection In a Mobile Home Park
Applicant Name: _El';zale-4 An A(Colm Date.Jw ZC03
Address: 31 _Aq „ N( Z 15q 6
Telephone: 14 - 90 z - q$O Z
Property Owner:
Lot Address:
hone: 9/0
Name of Park: ZZe,~/~e~/tir~,.~ ~1~&"Lot Number: ~f#
Parcel: 13`.0 0 - - eon S - o3 PIN: oh3o-5 7-5a 9q .1000
SSW DW TW (Size 16 _x 72J # Bedrooms 3 Year Zoog
Power Company_ Proems-, Ener 1 u ` 11a73-115' (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinoton:
5t
l
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:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
c
r
ature of Environ t 4l Health Specialist Date
cod )a2vi ~ /o o q 3 3
S
RQ'a W 1,7111211V PMA