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Application # f
Harnett County Central Permitting
PC) Box 65 Lilrington, NO 27546
910 -893 -7525 Fax 91 0-893 -2793
www.harnott.org /parmb
Application for Existing Septic Tank in a Mobile Home park
Applicant Name: Ldeu512r, C`r ri ��n ' (irk. Date: •�C3 l
Address: Yi 4
Telephone: i r�
Property Owner: Ar+aee r► C t.. rhgP V _--Phone; 1353.- 714 _a4M..._
Lot Address: rti
Name of Park: fn _ Lot Number: a 3 t
Parcel: !li 1tif PIN:
-.SW _DW 1W {Size i 4 x__A& j # Bedrooms . Year q aw
Power Company: (For Progress Energy we need the premise number.)
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 it false information Is provided on this
application.
You signature below certifies that all `above info tiorf is correct.
Signature of owner or authorized agent:
SEPTic
D® NOT SIGN BELOW -- FOR OFFICE USE ONLY
Authorization of Existing System
Si(gindtu4r(e;—ct-&Y#fronmenlaI Health Specialist Date
4108
06