ETApplication # NIS
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Harnett County Central Permitting i
P4 Box 65 Lillington, NC 27546
910.893 -7525 Fax 910 - 893 -2793
www.harnen.org /permits {
Application for Existing Septic Tank'in a Mobile Home Park
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Applicant Name : o,c -c,, A1ncrS Date: 44_ 1/, It-/
Address:
Telephone:
Property Owner:
�. ' • i ,
LotAddress: is . L ! •:.f .�
Name of Park: IL) is Ct 1'n S Lot Number: 13
Parcel: 0-1 1 Lb 10 LA PIN:��
✓ SW DW TW (Size �x9) # Bedrooms c_ Year' 19 9
Power Company -ASS (for Progress Energy we need the premise number.)
SDe,.cific Directions to Job from Lillington:
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: � n_
SEPTIC 4/08