ET1 I v~ C Application # . Ici 1 c1
Harnett County Central Permitting
PO Box 65 Liliington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Application for Existing Septic System Inspection for a Mobile Home Park
Date: - O
Name: "
Address: A V1 G 7
Telephone: 91* - / ,6L1- 8i g a-
Property Owner. .
Property Address:
Name of Park: L
Lot Number:
PIN: JA
-9r/9.2.
State Road Number. State Road Name:-{ayk,+ 4-1" le,1 .
SSW DW TW (Size , 4cj x,Zf1 ) # Bedrooms Year Zgff, "
Saeci'ficc Directions to Job from Lillinaton:
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6,ew RD. 51oi° g/d.d .0-Ac D-J 6f1y,rif~~Gi y~ .Q,D ~ii~E.Pi•
bs1 ~1~tiSsv ~.rr~r` ' J~R'EE~f Y` iYO~s~ DA/
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 inf tlon '
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
nature o Environmental Health Specialist Date
109d ,a„