ETDatp-:
Name:
Addre<
Teleph
Application #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
Telephone Number 910-893-7525
Fax 910-893-2793
Apolication for Existing Septic Systerr Inspection for a Mobile Home Park:
Property Owner: _
Property Addres(i.-'
Name of Par# :_j
Parcel: 13bu
State Pcoad Numb
SW-_.—DVV
✓/ll.�tl--+-- Phone:-?& i 6��T F.2fl
�l' r Gre
e er / Lot JNlrin)ber.
% State Road Name:
TW (Size 4x ) Beciroorns — Year
There is a $140.00.charge for this service. This certification is subiecl- to revocation if the
intended use of the septic system changes, or i; false information is provided on this
application.
You signature below certifies that all above information is correct.
Signature of owner or authorized agent:
SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
"SicAature of Envirahmentai Health Specialist Date
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