ETPUG-27-2010 09:27A FROM: COLINTRY FAIR HOMES
TO:919108932793 P.1
Application
Harnett County Central Permitting
PO Box 65 Llllington, NC 27546
910-893-7525 Fax 910-893-2793
www.hamett.org/permits
Applicant
Address:
Telephone:
Application for Existing Septic Tank In a Mobile Home Park
(~n,c 1 t`1 C r-. ~ P d VIP ? Date• 0
Property Owner: Phone: E r.~ 2L1 I
Lot Address: MCIM Name of Park: w Lot Number.
3 d PIN: ~
Parcel,
Year
W DW TW (Size x # Bedrooms
(For Progress Energy we need ttre premise number.)
Power Company:
S2&ic Direction to Jpb from LNlinuton:
There is a $100.00 charge for this service. This
his
or to ifica i lnt Is subject rprovided an evocation t" the
Intended Use of the septic system changes,
application. r,
You signature below certilles that all
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
At d
Signature o nvironmental Health Specialist Date
or)'
'P-ec cI
"ma
~13cl C
F131~~O