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ET1 ~J 1 Application # ,1_)9 1QQ Harnett County Central Permitting PO Box 65 Liliington, NC 27546 Telephone Number 910-893-7525 Fax 910-893-2793 Date: Name: Address: Telephone Property Owner. Property Address: Name of Park: r' State Road Number P- SW DW TW (Size Lot Number. State Road Name: eae '-'J _x1la) # Bedrooms !Year Specific Directions to Job from Liilington: .~/D 1iYfii6~ ~//diE-.p .0%~'•rs'f ©U ri0Ei9q/D~~,(1i/, lXr'/4 O/~.,5''ii9fE~P~ Oy10 Rte. ST/i° S/~ .~/d/1 r O.fJ /~.y inEt,iS•to!)~ir.~- .3~'EEff i` //D~sF ~,c/ L,E': T dZ ~°S7,P~r7 3~'<d7' 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 tion ect. Signature of owner or authorized agent: DO NOT SIGN BELOW - FOR OFFICE USE ONLY Authorization of Existing System , of Environmental Health Specialist Date ~l~dosr( 0/06 Application for Existing Septic System Inspection for a Mobile Home Park