ETApplicant Name:
A pp lication # 14 P'q 'q f � F'
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
Wind Ina Ri'aceP rwt rties.Tnc_&INTrhhnn`R•i MOO ate- `'1
Address: PO Box 5 i 45 sm- Rlrcl. N c g-J 3I
Telephone: _ql9- 9 5 a 9
Property Owner: lNindln6 Bid4e- Pr outies,anr- Phone: q Iq- -7.75- 9.569
Lot Address: King Charles Ave - Ca eron NC �9139 -u
Name of Park: k I' offs n of a w �~I P Lot Number: 175 -
Parcel: ,Q q 8555 no3q oa PIN: a - Is I -a7LIE
✓ SW DW TW (Size I x "lp } # Bedrooms Q Year �
Power Company: CbiJJ-G i EI e.0 1g C.. (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
-TaKe Hwv 2i nui of Li I iinq n +o NIC 2L{ j27 At 2�u 127 TO rn
ri�jjt. G about I. Li rn 1 -TICS ~f-urn 1Z fl- onto Mci<uyftiv4,rN Rd
Clo ab{at1t ra rn i 1e, on C! +-U (n lcff ()I-1b K, o� Char I-es A ve
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:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
le ce-�r o It 2c
Signature of Environmental Health Specialist Date
'�- /44'
m
SEPTIC 4/08