ETApplication #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www. harnett. org/perm its
Application for Existin Septic System Inspection in a Mobile Home Park
Applicant Name: o , 1J Date:
Address:
Telephone:
Property Owner: Phone: c,
Lot Address: 2
r
~ l
Name of Park:
Lot Number:
Parcel: f PIN: S woe
SW DW TW (Size x ~10 )
Power Company: # Bedrooms Z Year Z
(For Progress Energy we need premise number.)
Specific Directions to job from Lillinatnn-
You signature below certifies that all above
Signature of owner or authorized agent:
DO NOT SIGN BELOW - F OF ICE USE ONLY
f Authorization of Existing System
igna ure of Environmental Health Specialist
Date
2/08
.317/dS
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.