ET-77
Application # 1�rJ DQ��S b
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546rW.
910-893-7525 Fax 910-893-2793
www.harnett.org/permits cno Sua A K
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: L�3 o L2i_a DL__ Date: y -13 _ i -
Address:
Telephon
1 .� ♦ 1 1 ��
0 IN
Property Owner: Phone:
Lot Address: 4
Name of Park: Lot Number:
Parcel: i _ t 3� �DI( iJ3 PIN:719
.-SSW DW TW (Size # Bedrooms Year G}
Power Company: SL�'14MA1 7 (For Progress Energy we need the premise number.)
Specific Directions to Job from Llllington:
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 inform tion is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
v ZZ2 2-1
, S' nature ot nvi a al Health 8p6cialist Date
SEPTIC 4/08