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: Tla�....Date: 2 - � -1 r
Address: Py
Telephone.,
Lot Address:
C 1`0 €/y
Lot Number: -jlLf —yj� —01..W
PIN:
-PIN:15o7
—SW ADW --TW (Size # Bedrooms --- Year
Power Company: L' k-1 - - - - - - - - - - - - - - - - - - - (For Progress Energy we need the premise number,)
Sr)ecific Directions to Job frnm 1-illinciton-
There is a $100.00 charge for this service. This certification Is subject to revocation it the
intended use of the septic system changes, or if false Information Is provided on this
application.
You signature below certifies that all above lafQ atio i correct.
'i
Signature of owner or authorized agent,
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of ExisW'ig System
-7-
re of Environment &I'Health Specialist-- Date