ET~7 Application # 79
02,1~)()JF2 H
arnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Date:
Name:
Addre:
Teleph
Property Owner: I
Property Address:
Name of Park:p
Parcel:
State Road Number:
,./SW DW -
Road Name:&
) # Bedrooms
is
w M bt t A --the. Yi
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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 abov i formation is correct.
Signature of owner or authorized agent: loha Lmo
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature f Environ
I Health Specialist
Date
(2A93(o , Y , N ii//y S ,0'0,
Application for Existing Septic System Inspection for a Mobile Home Park
Speck Directions to Job from Lillington: