ETApplication # J
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: t Date:
Address: �t.-�-
Telephone: C'j/
Property Owner:
Lot Address:
hone: �/1 433 V3ZV
Name of Park: o'e k ,- cj�Q 5-V A ar
SW D1N TW {Size -�=-�x-��� } # Bedrooms,_ Year_
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinoton:
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
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
'5Z
nature f Environmental Health Specialist Date
SEPTIC 4/08