ETApplication #
Harnett County Central Permitting
PQ Box 65 Liliington, NC 27546
910 - 693 -7525 Fax 910 -893 -2793
www .'hamett.org /parmits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: Date•
Address:
Telephone:
Lot Number:
X ?V7--�V '7 3
Parcel: - ��- dDW ` �/( PIN:
SW DW TV11 (Size�_x19 # Bedrooms _ ._ Year I.
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
Signature of owner or authorized age
Authorization of Existing System
Environmental Health
SEPTIC
Date
'�ec�d K/3t-,/t-3 4/08