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Application # SQG
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525 N D
Fax 910-893-2793 D
Application for Existing Septic System Inspection for a Mobile Home Park
Date: 8
Applicant Nam : ~
Address:
Telephone:
Properly Owner: El I
`A Phone:70~ 5?S-3
Lot Address: A& ICZA4.11
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Name of Park: Lot Number: 3
Pa,rc~~: PIN:-T9
S(, - $SB
_LZSW DW TW (Size /4 x -2t ? # Bedrooms Year 2-6 p
Specific Directions to Job from Lillington:
60
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.
You signature below certifies that all above information is
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
nature
nvironmental Health Specialist
7 -o/6
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Date
2117 / t °
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