ETPA K1'7
Application # J/ ap ~ 2
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: L.tn~ S ut e u' L/,q r~ Date: `3( T?-t ~A Zd l 1
Address : P, 0 ~ E:Ao x l)at S S d1 C 'Z4s-3 et L+
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Telephone: a_0 -"4 8- L- 5=
Property Owner: 1=+`nv1 Pdw V,-s +i!f Vu`i- W~irt~SPhone:°00.
Lot Address: 5~l_..a -0+ V esf ' is y e,~ ~+~c c uG, ~C 7 S'b
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Name of Park: Lot Number:
Parcel: PIN:
k SW DW TW (Size l t x -In
) # Bedrooms Year I
Power Company: P roAv'esS qtr, oS:A (For Progress Energy we need the premise number.)
~ZSk°i°7 Z-4 P+~e µn~s it'
Specific Directions to Job frQm Lillincton:
Ill G Z, 7 Sc3 w'\n , to F - i e~ t -A
►~-.~f c 1 W , 2`~ 4 ~ .
P \ ,!n In a i- A-t,, e e,-, vt_A en 17 s e 2
d e s i r e t_v Z i s a4- -r y e e +P 0 tA
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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 inf on' Corr t.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
uthorization of Existing System
Signature of Environment Health Specialist ate
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