ETApplication # C 0 500 ON 94
Date
Appl
Addr
Telel
Property Owner:
Lot Address:
Name of Park:
Par I:
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to
SF ,
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
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z6b Lot Number:
D -1J CA PIN:
(Size • x # Bedrooms Year
You signature below certifies that all above information is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
T'/~n ~ S ZS -p
of Environmental Health Specialist Date
J1o2'/1Q U / ' 5107
Application for Existing Septic System Inspection for a Mobile Home Park
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.