ETV
Application #
Harnett County Central Permitting
P4 Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.hamen.org/permits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: bnd-,-)ei5 Date: Jr
JPA
Address: CO P ! wn M. c-�flttf�Cv IIQ 15 4t)
Telephone: 3� 3 -
Property owner: 141 11 C&L± L s'C.� LLr— Phone: � U 3 - 01
Lot Address: IL 590� wn 9d, l Stell ,- IK
Name of Park: Lot Number: J
Parcel: 050co35 Off' OQ PIN: 0(035 Y) - 1 100. c oo
SW __/DW TW (Size 1JU ? "x tom) # Bedrooms 3 Year 7-015
Power Company:t55 F.rtja &Vq (02,q l6 For Progress Energy we need the premise number.)
Specific Direction,§ to Job from Lillington:
•Ther~ o-t�D j +Si"oW^ t -d Zr— -tt, LA51c L,O'r an il^� LC* -r,
There is a $104.00 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:
SEPTIC
.• NOT SIGN BELOWFOR OFFICE USE ONLY
Authorization of Existing ystern
w
�.,w. / .... LTi►
of .nmintal Health SpecialistDate
4108.