ETApplication # IJ - 50r-,--ZS t h1c
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 a_*
910-893-7525 Fax 910-893-2793 l : 2 gwt 1
www.harneft.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: D &d'-r z. Date: Zl - i (
Address: --2 ~=3,--' ;
Telephone: 1Z0 - 9 73 -•s'3,91' Email
Property Owner: a & - ti Phone: 910- `,F. t33~
Lot Address:
Name of Park: c diad Lot Number:
Parcel: _I30cooo opci 0 PIN: 'ZB3.caD
_ZSW DW TW (Size 7 x7) # Bedrooms:-_ Year: (SJ'/:2
Power Company: r~'Lc,~1 ~7ilit~i (For Progress Energy we need the premise number.)
Saecific 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 information is correct.
Signature of owner or authorized ag
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date