ETApplication # / 2~9z
Applicant Name
Address
Telephone
S S3
:1, .5rd
Prope, l er ~ e- ✓
Lot Address rc- E'-✓~
Name of Park se-.(- n e s Oho" Lot Number
P3 I PIN
Parcel d
SSW DW TW (Size 11 x_ # Bedrooms- Year
Power Company 42-q" f -C g6f- (For Progress Energy we need the premise number)
S cific Directions to Job from Llllm ton
~'}1 Rte 5
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 f ogpri onnis c wpctt
Signature of owner or authorized agent
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
of Existing System
Signature of Environ
Specialist
l3 1)
at
SEPTIC 116 ~ 2 j
Harnett County Central Permitting
PO Box 65 Lilhngton, NC 27546
910-893-7525 Fax 910-893-2793
www, harnett org/permits
Application for Existing Septic Tank In a Mobile Home Park
C, ~ j., L P,-- - - et/S,~ e,-- Date -5- C-S
ozxl 6-S
hone S-.S -S
4/08
s/ is