ETApplication # I �� S: 3 �0
Harnett County Central Permitting t 00a G91 'q'7 5 -
PO
PO Box 65 Liilington, NC 27546
910-893-7525 Fax 910-693-2793
www.harnett.org/permits C.04y'_A_: of 10 to 0
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name:
Address:
Telephone: M2
IN
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Property Owner: �r r'M o�S'�►�^�-�''��� � Phone: r. D • l kr
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Lot Address: ----
Name of Park: Lot Number:
Parcel: t}f PIN: 2-2.-
W DW TW (Size x_re*)) # Bedrooms 3 Year
Power Company: (For Progress Energy we need the premise number.)
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 informa is correct.
Signature of owner or authorized agent:
SEPTIC
00 NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
/t
SO/ature of Environmental Health Specialist
9
7-75—,5—
Date
4/008 /// py
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