ETApplication # ! _ 500a C.U
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 System Inspection in a Mobile Home Park
Applicant Name: 4ri Date: Z - ~l
Address: 1"/ -4V o ~Z o -t' C Ce
Telephone: y9 ° lJ
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Property Owner: 7e~ X- o Av /V Phone: l 91 S
Lot Address:
Name of Park: ~'°u f~Y fah,`/n h~ ce 5~~~~,JLot Number: 2
Parcel: PIN:
__X_SW DW TW (Size x 70 l # Bedrooms 3 Year ZJ
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
lJ`Z
1'L04 l ~~C' ! y X_ -
10 7. C-L
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 agent: /wee
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Auth
orization of Existing System
1-1
Adl'~_ C*"'-
Signat4onviron'mental Health Specialist Date