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Application #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Date:
Applic,
Addre:
Teleph
Property Owner Phone: r cic's &3a-No- (
Lot Address:
Name of Park: Lot Number:
Parcel O PIN: .72
_W DW TW (Size ix_-~ # Bedrooms_ Year
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Specific Directions to Job froLLillington:
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There Is a $100.00 charge for this service. This certification is sub
jest 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 inf ation is orrect.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
ignatur o ,f-Environmental Health Specialist Date
r
Application for Existing Septic System Inspection for a Mobile Home Park