ETApplication #
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
916-893-7525 Fax 910-893-2793
www.harnett,org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: C ('g A Date;
Address: Q _,5�L�/> t r�,n f N � . F" •2
Telephone:
Property Owner: 9,1 r;'e-:k> Phone:
Lot Address: /. "yF fY 1
Name of Park:/, -J K' , ,,sr Lot Number: %
Parcel: 'K PIN:'
4Z.SW —,-''-DW TW (Size L4i x-u—b) # Bedrooms 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 information is correct,
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Ig ature of Environmental Health Specialist pate
SEPTIC
4108
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