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Application #
Harnett County Central Permitting
PO Box 65 Liilington, NC 27546 ~,p Q~/LQOU
Telephone Number 910••8934759
www.hamett.org
Application for Existing Septic System Inspection for a Mobile Home Park
Date:
Name:
Addre.
Teleph
Property Owner: -L
Property Address: s
Name of Park: 1)f
State Road Number.
Lot Number:
You signature below certifies that all above informat correct Z~-'4
Signature of owner or authorized agent:
DO NOT SIGN BELOW -
OFFICE USE ONLY
Authorization of Existing System
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Signature of En
Specialist
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ate
S
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There is a $25.00 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.