ETApplication # k
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: ki MV Date: 1-5
Address:
� C
i0jlyl�,
Telephone': � lio- <�()i?- '2A
Property Owner:
Lot Address: Z -
Name of Park:
hone: -.10,
Parcel:
—SW ---" DW
Power Company -
PIN:
TW (Size ?-Lx-J'L) # Bedrooms '-2) — Year 200
or Progress Energy we need the premise number.)
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 an this
application. I
You signature below certifies that all above information is
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature' of Environmental Health Specialist Date
SEPTIC
4;08
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