ETApplication
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893--7525
Fax 910-893-2793
Application for Existing Septic System Inspection for a Mobile Home Park
.-1 r , / _ --
Date:
Name:
Address:
Telephone:
Property Owner: 11-W4 /C
Property Address:
Name of Park:
Parcel: 1.� E
State Road umber:
SW DW TW (Size
Phone:
Lot Nu
5' PIN*-
>tate Road Name.-'
x'5�) # Bedrooms
J
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
Signature of EnlvironmeMil Health Specialist Date
10106
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