ETApplication #
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Date:
Name:
Address:
Telenhnr
Harnett 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
Property Owner:
Property Address:
Name of Park:
Parcel: 0 Lat Number.
State Road Number: PIN 9 77 9762 ocyv
SSW DW State Road Name:
TW (Size x_`) # Bedrooms Year -
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 information is correct.
Signature of owner or authorized agent:
v
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
nation of Existing System
Signature of Enviro
Health Specialist
02..()1.0 y
Date
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