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Harnett County Central Permitting
PO Box 65 Ullington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Application for Existing Septic System Inspection for a Mobile Home Park
Property Owner
Property Address:
Name of Park:
State Road Number.
_ - SW DW
You signature below certifies that all above inf lion
ct.
Signature of owner or authorized agent:
00 NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
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nature of Environmental Health Speclalis
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Date
//80/0 g W
10M
A-
-x-7-.0-J# TW (Size ~Bedrooms Year _422Z_
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.