ETApplication # ~~M
7-
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Date:
Applic<
Addre:
Teleph
Property Owner: iA Ply y
Lot Address:
Name of Park:
Parcel: 13 ~)66q oZ
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hone:
Lot Num(Dbler:
PIN: 6 :70q-
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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 correct.
Signature of owner or authorized agent:
11 z4AIL4-4 -
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
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-n,- t -.6ml SSig'na tur of Environmental Health Specialist Date
Vl/~3 'S
RRR , ~X Application for Existing Septic System Inspection le.
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Specific Directions to Job from Lillington:
.
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