ETApplication # I:515UD3 l 5(Q
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application or EtCisting Septic Tan �C in a Mobile HomJ'Prk
Applicant Name: '-` )r (_nh- liP� Date
Address: q e
Telephone: q ft S 5 J�
Property Own
Lot Address:
Name of Park
Parcel{5105 1,5 PIN:a� I's SIS - td q U , ouCJ
SW aor-DW TW Size 2_�_x_f5(. ) # Bedrooms _3Year tqC)3
Power Company: �, ;,, ,a, . (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
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of nvironmental I�Si�th Specialist fhate
SEPTIC fin„ d 11A(/(_lr 4/0