ETApplication # Soo 191L,1(2-
Harriett County Central Permitting
PO Box 65 Ullington, NC 27546
910-893-7525 Fax 910-893-2793
www.hamett.orglpermits
Application for Existing tic System Inspection in a Mobile e
Applicant Name: r--A mt. I I
Date: ,
Address:
J Telephone: -%Cj.
Property Owner:
J Calf) Phone:_ °M S -a Lot Address: r Co d 2
Name of Paris: Lot Number:
Parcel:
PIN:
SSW DW TW (Size _(x^? 1 # Bedrooms--,2- Year
Power Company~~~f (For Progress Energy we now if* premise number.)
Specific Directto to Job from LLf~i+to~:
You signature below certifies that all above
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR bFFi E USE ONLY
Authorization of Existing System
3-1101-08
'51 nature of Environmental Heal#h Specialist Date
31/3 /0 ?
Al
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.