ETt~W Rec' 131171d"
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-4759
APPLICATION FOR EXISTING SEPTIC SYSTEM INSPECTION FOR
MOBILE HOME PARK
Date:
Telephone: Cf 1 qc/-
Name:
Address:
Mailing Addre
Property Ownt
Property Ad&
State Road Nui
Name of Mobile Home Park: Directions (please give concise, complete directions)
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.
Your signature below certifies that all above information is correct.
Signature of owner or Authorized Agent: /-Z 1,Z
Do NOT SIGN BELOW - FOR OFFICE USE ONLY
A thorization of Existing System
Signatn of Environments ea Specialist
I y-DY
Date
06/02
3/x/v 'fs