ETApplication # M- 5 0 0._ 2 U OO'?..
Harnett County Central Permitting
PO Box 66 Lillington, NC 27646
910-883.7525 Fax 910-883-2793 r r ~#~7•~,
www. harnatt.org/permfts u-, _ll -r,
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name:
Address:
,P-y-o 4
Telephone: ! `J
Property Owner: "J o hn+~u -fir ; r - Phone; ?1 19/'Pla
Lot Address: LJWI-Av, L440-
Name of Perk. nes in Lot Number: 2
Parcel; PIN;
St ''b V T (Size x~ # Bedrooms _ year ~
Power Company:_ fr.J rl?'kj 1, .i ~'r -i ~ (Far ProQrosa Energy we need the premise n6mber.)
gHic Difectivns to Job from Uliinaton:
There Is it $100.00 charge for this service. 'this certification is subject to revocation If the
Intended use of the septlo system changes, or if false information is prorrfded on thls
application.
You signature below certifies that all above infoMation is
Slgnature of owner or authorlxed agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
hvrlaatkrn 4f Existing System
Signature of Environmental Hera Specialist p to
S