ETApplication #} �� x
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910- 893 -7525 Fax 910 - 893 -2793
www.harnett.org/permits
Applidation for Existing Septic Tank In a Mobile Home Park
Applicant Name: j,a,,10r &ry+ixers L-6\5 -111 id Date:
Address: C.ti,t 11C
Telephone: q l 9 —
Property Owner: Tc�.-4 �ro clefs AJ%"4cAs Phone: q 1 q
Lot Address: lam ter: �.,vi L l
Name of Park: - I t Odod5 E.5-4-4 -s Lot Number.
Parcel: PIN:
�
C SW DW TW {Size 1_x,-;,r. ) #Bedrooms c Year
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Liliington:
r %r k+
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 correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
7
,-'Signature of vironm ntal Health Specialist Date
SEPTIC
f: ;
4/48