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Application # n.1%
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: C s a LAC_ Date: 67_4q - I �5
Address: H!i _L_Q Ck�Wo_�t4 C
Telephone: _._ C? ICA - L
Property Owner, Phone:
Lot Address:I y
_
US -
Name of Park: _Lot �uber:w,n -4 7
Parcel:
SW TW (Size x� Year t
Power Compan # Bedrooms
--(For Progress Energy we need the promise number,)
5��cific Directions s to glob from L&QQ:Iiq t_g_
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 co rest.
Signature of owner or authorized agent: 6
")k
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of 'Environme I Health Specialist a-te-
SEPTIC 4,08 Is