ETApplication #.
Harnett County Central Permitting
PO Box 65 Ullington, NC 27546
910-893-7525 Fax 910 -693 -2793
www.harneft.org/parmits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name; Date:
Address:
Telephone:
Property Owner:
rMM;ii7oTiT4-0&§ULI RM
Name of Park: LA4,1 J1 Lot Number: t :q-
Parcel: PIN:
SW —DW TW (Size J Lx_6LQJ #Bedrooms Year 1q9 C)
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 If false Information Is provided on this
application.
You signature below certifies that all above i"Aliatp is �offe4
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
-4L
:—r—'Pature of Environmental Health Specialist
SEPTIC
6'13`/.3
Date
4/08
3