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Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-8934759
www.hamett.org
Application # d-~ O Cll jv
Application for Existing Septic System Inspection for a Mobile Home Park
Date:
Name:
Addre;
Teleph
Property Owner. ` J C'-) 7"-~C4 c
1-1ropertyAddress: v4,S i_st,-) l U;S lio"
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Name of Park: ( (V1 W 1'y) t Lot Number.
State Road Number:
Specific Directions to Job from~ill 0 torn 69,
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There is a $25.00 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:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
L-_'~l z
Signat a of Environmental Health Specialist Date
a/a~lo&
S
08104