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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/perm its
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: eg Date:
Address: '4ZI —
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Telephone: Of
Property Owner: 6w��VF— A el Phone:
Lot Address: A
92
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Name of Park: &kji5 &Agg: &114t Number: IZO
Parcel: > PIN:
--SW W TW (Size 1-41.. XIL #Bedrooms Year
PowerCompan
.(For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
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4:4-Al-
AIII-) 110-S, /
There is a $100.00 cl
intended use of the
application.
IM
lei
arge for this service. This certification is subjec
septic system changes, or if false information
You signature below certifies that all above information is correct.
Signature of owner or authorized agent:
V
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
k
I tar revocation if the
is provided on this
Authorization of Existing System
-7
nature of Environmental Health Specialist Date
SEPTIC
/V/
4/08