ET'51 OF Application # . 1 C1
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:
Addrea
Teiept
Property Owner: .
Property Address:
Name of Park: L
Lot Number:
PIN: /d
State Road Number 1925-5 State Road Name: teyil/ .ry" Xao
SW DW TW (Size x ?D ) # Bedrooms 2.:~_ Year 1,7,T7
Specific Directions- to Job from Lillington:
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Apr
There Is a $100.00 charge for this service. This certification is subject to revocation if ft
intended use of the septic system changes, or if false Information is provided on this
application.
You signature below certifies that all above Inf Lion ~cQrrect,
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
'Authorization of Existing System
Z- 'f -OR
nature of Environmental Health Specialist Date
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