ETApplication # tJ j7p
° Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910- 893 -7525 Fax 91 0- 893 -2793
www.harneft.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: Date:
Address:
Telephone:
Property Owner:
Lot Address:
46 9"710
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C'/i J'?" 'J ;5
.r 1 A.Gi733-z
Phone: / ' ° r
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Name of Park: — Lot Number:
arc I: 0.?- ?S % 7 u-26-] - v3 PIN:
7 PSW DW TW (Siie'IJW x
Bedrooms 5 Year 9 9
Power Compan (For Progress Energy we need the premise number.)
Saecific Directions to Job from Lillington:� -- l `
r"t".r r h
a .0� /e5 yc. 7" 2 1 d /5'r_d,ti
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 inform ' n is correct.
y
Signature of owner or authorized agent:
if
DO NOT SIGN BELOW —FOR OFFICE USE ONLY
uthorization of Existing System
7 Z l G1-7
ignature of Environmental Health Specialist Date
SEPTIC 14"&Y 4 /08