ETApplication # 15 0 n OQ ~A/ 01
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: Johan lai"-CLYh Datc
Address: 52' 'i1 G S ~ fir o 4
Telephone: / J
Property Owner: "JohnncI 4-0 ` c) Phone:' 8~q~
Lot Address:
Name of Park: lam, 4P Lot Number:
Parcel: ,L 01> Ac) C> f o
-t PIN _ US-7 .7 -
SW DW _ TW (Size -Y-xa # Bedrooms Year,
Power Company: (For Progress Energy we need the premise number.)
SRecific Directions to Job from Litlinatan:
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 certitles that all above Information is
Signature of owner or authorized agent:
SEPTIC
00 NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environments Ith Specialist Dale
~a
4/09