ET5 p g Application I Cl I Cf
Hamett 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:
Address: - . 4
Telephone: 91*
Property Owner:
Property Address:
Name of Park:
Lot Number.
PIN: /6 ~
State Road Number: 39_5'ff' State Road Name: &-I',/ `V
I.'- SW DW TW (Size fix, # Bedrooms . Year 1X1
n:
0 &Me ""X ~r~,ssr 0Z f~s' 0 P/,ow< V, e o/ds~~sE.F/. 0
~,dtiEV lc,QoyE i4lJ. ~ Si ~i° S/6.r .0/Gif r D•~l COy,G~ V~
~4'vr,
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 in Lion ect.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
'Atithorization of Existing System
nature of Environmental Health Specialist Date
il'V10 v
10104