ET° Applicant Name
Address:
Telephone:
1
Application ff
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 T/annk in a Mobile Home Park
4- c5 9!6-v s"7176
7176
Property Owner: A dt C ,q f d Phone: ty- '/ 0 �7
Lot Address:
Name of Park: I r it Qar Lot Number:/c1c�-r.� /'St�
Parc l: ALV- e? 7 v3 PIN: tah'� ��
7
SW _DW Ad_TW (Si x) Bedrooms 5Year___
Power Company: tFor Progress Energy we need the premise number.
_Specific Qirections to Jab from Lillinaton:
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 n is correct.
Signature of owner or authorized agent:
USE ONLY
Authorization of Existing System
Signature of Environmen , Health Specialist p to
1.7 Vi
SEPTIC
4108
DQ NOT SIGN BELOW -FOR OFFICE
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