ET~ SAr,ANNED Application # 10-5 -2 7 Cjg
Harnett County Central Permitting
PO Box 65 Liilington, NC 27546
910-893-7525 Fax 910-893-2793
www.harneft.org/permits
I
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: 71io
c~ Ytarv~ Date: p
Address:
Telephone: 1
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Property Owner. _ T~ ; 1 fell
Lot Address: Phone:
.
Name of Park:
Parcel: o,~,~ M M t
Lot Number:
PIN:_aUL
TN (Size SSW DW :
_J!! x 2o) # Bedrooms
Power Company
(For Progress Energy we n
^i Lilliii
S @CIfIC Dir@CtIOnS t0 lnh frn v I
isso,oov
thwpremise number.)
There Is a $100.00 charge for this service. This certification Is subjec~ to revocation the
Intended use of.the septic system changes, or If false information is provided onI 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
gnatur@ of Environmental Health Specialist
Da
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