ETApplication # . ~ 1 ci 1 Cl3
I c-' PHarriett O Box 5 L~i gCentral ton C 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Application for Existing Septic System Inspection for a Mobile Home Park
Date: 44 - D
Name:
1741*5
Address: . w
Telephone: 91ti - / ~-1- - if/ q s
Property Owner. Phone: J/9-0/.?
Property Address:
Name of Park:
ga r5 4 - Lot Number: l.5
Parcel: 07/L,o3D0,25' PIN: /609/y.2/S9
State Road Number. 39-67 State Road Name:_"kTy '&J"
SW DW TW (Size _,Z~4_x 2o) # Bedrooms Year___
Specific Directions to Job from Lillinaton:
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IWA ff.
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 ect.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
'Authorization of Existing System ,
nature of Environmental Health Specialist paw '"g'-
llwal~ 10/w