ETApplication
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910_893-7525
Fax 910-893-2793
Application for Existing Septic System Inspection for a Mobile Home Park
Date:
Name:
Address:
Telephone: i
Property Owner: 1111 114 Z
Property Address:
Name of Park: r . ..... Lot Number:
-77/4�7
State Road Number: state Road Name:_ -T . /'i"'
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:
00 NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
--Signature of Environment I alth Specialist
11
8106