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ETl lT I "IV Application # 11-500gloi O-L Harnett County Central Permitting . D PO Box 65 Liilington, 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: Ul d A , S ~ e V V`cky'c~ Date: t Address: Tea s- 0L Telephone: c(_ lD _ p L„ Property Owner: Fya,- ,6 ~m w k 16A+V1Ii'e4 v%4 s Phone: gLO!-t9© --3IWW Lot Address: (0"t T;:4l®h 1~ v, ad wry Al C--. Name of Park: E;,,; , La yeC646 M 4'P Lot Number: (,o Parcel: 03('- 7t s97 cr--~^" PIN: SW DW TW (Size 14 x # Bedrooms Z- Year Power Company: (For Progress Energy we need the premise number.) Qs4b-f, b Qsd Specific Directions to Job from Lillinaton: kn i-Q awl s mac, AA N- p-, 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 n i rre . Signature of owner or authorized agent: NOT SIGN BELOW - FOR OFFICE USE ONLY uthorization of Existing System L3 Signature f Environmental He h Specialist late s