ETApplication
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: -1-A04- L-0�,) . .... . Rel P a Date
Address: —5-6 d57 ,UC- Z-7 A-V f
Telephone: __.qkc( to-SCY
Property Owner: Phone: ...-..qsq_..G3q "34S3
Lot Address: al(wryer
Name of Park: ?XVA�-w 00 Lot Number:
Parcel: C�) i U ur' C-,a� (A PIN:
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,'ISW —DW _TW (Size # Bedrooms,-- — Year -- o�
Power C o m pan (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
r yeH—5b '2 6
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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 information is correct.
Signature of owner or authorized agent
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
n�ature of Environmental Health He�Specialist� Date
SEPTIC A: ram
4/08
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