ETApplication # ~O/0 77
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Application fo Existing Septic System Inspection for a Mobile Home Park
Date:
Applicant Name: '
Address: -
Telephone: 41 p S 7 ~s-
Property Owner. Phone:L
Lot Address: `j r r L.
Name of Park: rMc' 1VA! Lot Number:
Parcel: 0 d 5-1 PIN:
SW DW TVU (Size Z41 x CZ ) # Bedrooms _ Year i
Specific Directions to Job from Lillington
5-1 ~11
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
Signature of owner or authorized
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
1612
Wuign of nvi o ntal Healt Specialist Date
5/07
IC/ l7/6`7~~