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05/14/2013 11:15 #499 P.002/002
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Application #�J
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910 - 893 -7525 Fax 910 - 893 -2793
www.harnett.org/permits
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Applican
Address:
Telephone: :2,7
Property Owner: �f. a n JL4 r 1>�Phone:
Lot Address: -3 /Q..- 4 a Vt IP
Name of Park:.
Parcel:
Lot Number:
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SW DW, —_TW (Size %'s/ x��# Bedrooms_ Year g�
Power Compan (For Progress Energy we need the premise number.)
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Specific Directions to Job from Lillington: Y
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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 cor ct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW – FOR OFFICE USE ONLY
Authorization of Existing System
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ignature of Environmental Health Specialist Date
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SEPTIC 4/08