ETApplication # i1-500-Z0141
Harnett County Central Permitting
PO Box 65 L.illington, NC 27546
910-893-7525 Fax 910-893-2793 ` . 1 _
www.harnett.org/permits
Application for Existing Septic Tank In a Mobile Home Park
Applicant Name: ASfIL.-ay twgp _ 1~ ' 2dt
Date: I
Address: 12-o t"guww go. ~ ~ rv c 339
Telephone:
Property Owner: hohtrsk URZO' LLJCs
Pitons: X10~ 1
Lot Address: 3 f e L- p Pt., AJ C 2sr
Name of Park: hgl tgg 0091a WE 7' kk Lot Number: / $
Parcel: 0?- 15 01 Bost- PIN: 5al-11~M O* X33,000
ZSW DW TW (Size x fO ) # Bedrooms --3_ Year / 7
Power Company: '?Roc,vzA-5s
(For Progress Energy we need the premise number.)
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 aboI fo atl is c rrect.
Signature of owner or authorized agent:
00 NOT SIGN BELOW - FOR OFFICE USE ONLY
Authoriz ion of Existing System
t
Y -Zt~--le
gnature of Environmental Health Specialist Date
C., r= 11 0-7 `1
SEPTIC
4/D8