ETApplication # St U I q Co2~.I
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893.2793
www.hamett.org/permits
Application for
Applicant Name:
Address: G
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.
Telephone:
Property Owner:
Lot Address: &
System Inspection in a
_ AV-A: f%A -~Q,~
Park
Name of Park- ~ ~ ~ Lot umber: °I
I: PIN:
W DW size 1 -q x7U
7S
# Bedrooms Year
Power Company MANN V-1 in !
_(For press Energy we need the promise number.)
it' Di i o Job ro
=6- Vs 210
I
t
3/de
You signature below certifies that all above
Signature of owner or authorized agent:
DO NOT SIGN BELOW -
USE ONLY
Authorization of Existing System
ignature of Environmental Health
Specialist Date
e
M~UN
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