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: Application #
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: 14 a Date:
Address: !4 r1&1 AhC cR Lo A1tg12W) A//? 1.c z2 Afi -7 7-40
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 0
910-893-7525 Fax 910-893-2793 4 4 S 1
www.hamett.org/permits
Telephone: q1J &-3q 32.119 Email:
Property Owner:
Lot Address: 501 F
L44E,
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Name of Park: Lot Number:
Parcel: 0`10 X73 Wit PIN: ~tc4~2 Zit -25Su ot>o
-IzSW. -.,-pW TW (Size L_x _5 } . # Bedrooms:_ Year:
Power Company: (For Progress Energy we need the premise number.)
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Specific Directions to Job from Lillington:
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 a
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
z1-11
re of Environmental Health SDec alist Date
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