ETApplication #
Hamett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Date:
Name: _
Address:
Telephone:
Property Owner. -___1_c rn p 4 S
Property Address: -__LZ o ~~cs a
Name of Park: L~¢ S,q TER A i -
State Road Number. State Road Na
Lot
You signature below certifies that all above info ation is co ct.
Signature of owner or authorized agent: l t
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signa re of Environmental Health Specialist -7
Date
8/06
Application for Existing Septic System Inspection for a Mobile Home Park
5?-2k-0
Curt N t ~0
!2!1) r'- - 2 0
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.