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Applicant Name:
Address:
Telephom
2524930300
PAGE 02/02
00 2 4Z-
ApRpcatien # .15 3,
Harnett County Central Permitting
PO Box 65 UNington, NC 27546
910 -893 7525' Fax 910-893-2793
www.harriett.org/permits
Application for Existing Septic Tank In a mobile Home Park
Property owner. h m6gn - rzG thick G �6ja,-k- Phone: a _11+z2 , 5
Lot Address: 4 I :
F. -mgr
Name of Parts: �..jjtj�t Lot Number. 412 _..,...
Parcel:_ 10 - 7 QX ' PIN:
✓ SW 01M TW (Size 14 X Jtq # Bedrooms Year �5
Power Company: .. ,� (For Progmas Energy we need the premise ntimber.)
R�'. .
aw
OW Lovie-Ar
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 caffBet.
Signature of owner or authorized agent:
1010,11 i 19MUM11 r • ' e
Authorization of Existing System
Sign tore of nvironmental Health Specialist Date
SEPTIC US �
100