ETApplication # 1556S -773
Harnett County Central Permitting "" ����
PO Box 65 Lillington, NC 27546 brvT bt-
910-893-7525 Fax 910-693-2793 y (,�, ,
www.harnett.org/permits V `
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: 1 Ae . t.-, , R.., 1�"�,p ot; A/r-- Date:
Address: w, (t• -. �� s L - 1iKs �. ,4,L� zea t
Telephone: rt l`t (-3"i 3y 3 3
Property Owner: .0 6 Phone: el k
Lot Address: ' L4 ML-La� ^J!- -2--k�
Name of Park: (jg4�1 rkt.4 Akobt.L Ra Lot Number: 20 AIL
Parcel:U-71UO� 01a,iJ PIN: �inl)��C 1-$�.ocx�
SW DW TW (Size 14 x 1 c.>) # Bedrooms _:3, Years_
Power Company: N ,, Rrb$� st (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
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 informationiscorrect.
Signature of owner or authorized agent:
DO NOT SIGN BELOW — FOR OFFICE USE ONLY
Authorization of Existing System
Heatth Specialist Date
9kV1i5-
SEPTIC 4108