ETApplicant Name:
Address: J r
Application
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
for Existing Septic Tank in a Mobile Home Park
Tr rcDate: 6- 3 -
M
Telephone: CI ) q ' & o O J
Property Owner: V'n61J'2- calccl-t Phone:
Lot Address:
Name of Park:
Lot Number: * !S -
Parcel: PIN:
SW DW TW {Size x - } # Bedrooms �� Year�q�
Power Company: Prod rtsS Cyy'� u (For Progress Energy we need the premise number.)
7-/ - ward 3 -
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 aboveinfor tion is co rect.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
=3k Z 6 -r 7-.' z
re of Environ ental Health Specialist Date
SEPTIC
4/08
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