ETApplication # � J 50 0 J \G'
Harnett County Central Permitting t
PO Box 65 Lillington, NC 27546 U
910-893-7525 Fax 910-893-2793 //
www.harnett.org/permits VA - I -� I S
Application for Existing Septic Tank in a Mobile Home Park
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Applicant Name: Inti i�,lej6C.I 1A1rht3 1-nc (JJr10itKr)�, ate"la-Z
Address: PQ &Nk 5 HE, ' cO)E fi NC a1�31 514
Telephone: UIG `1"15 GSBq
Property Owner: windinQ2 C1�l2umt Zn(. Phone: C)lq-M GS�'9
Lot Address: 1A5_Kin G-C.hcttLCS_AVL Molifi i i NC a83aL#
Name of Park: MLAIrielharn MHO Lot Number: a3
Parcel: ( q 65 W PIN: q565-61 --)Ni
✓ SW _DW TW (Size _x i(.o ) # Bedrooms �_ Year aC04
Power Company: U nfaA I PIc jY) C. (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillinaton:
TaKe. Hwu al t)ut [)f 1-1111 n4tiji +b NC QLAI +urn n�htgoabouT I,y
m k les it if n ILD IXr1n MC kNtz)wn -Rrl Go abbcfl a m I I c ann -b a,
le -a Dnb Kine C.hnr It_s Ave..
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: �� __Z'
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Z<.- 4�� 115-11 /z ZI (21tJ`
Signature of E ironmental Health Specialist Date
SEPTIC 4/08
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