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Application #
FEB X 4 iA Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 ,~i~'PF
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Nome Park
Applicant Name:
Address: 115,
Telephone:
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Property Owner: r 1o hnncei 4.a ircI!'` Phone:4fi9 9 9f"Qe
Lot Address: .
Name of Park: nes 11,44P Lot Number: -T
Parcel: , biol PIN•`k5"73.00V
W DW TW Size x~- # Bedrooms Year
Power Company: (For Progress Energy we need the premise number,)
Specific Directions to Job ftom Litlinaton:
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 infojx atlon Is
Signature of owner or authotlzed agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
c ,
gna re of Envvonmental Health Specialist ate
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