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ETApplication # ~ 6 ~N-' Z 6-6- 5- Z , Harnett County Central Permitting PO Box 65 Ldlington, NC 27546 910-893-7525 Fax 910-893-2793 www harnett org/permits Applicant Name Address ication for Existing Septic Tank In a Mobile Home Park r V I I I A, i \ ~ ~ t Y O I Date~;- 1 1- t 0 Telephone Property Owner AV t..LC (2~~-C.I C~J`t t one Lot Address Name of Park Lot Number ~C Parcel P7 /d 12 11ZO PIN l 7a - 3~©. 060 Year SW DW TW (Size JLJ_x~J # Bedrooms Power Company Z~ ss (~'Vk %r L, -(For Progress Energy we need the premise number) Specific Directions to Job from Lllbnaton 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 1 You signature below certifies that all above, mf ab n is corre G Signature of owner or authorized agent DO NOT SIGN BELOW - FOR OFFICE USE ONLY Authorization of Exl tang System ature of Environmental Health Specialist Date SEPTIC t08' 1 8 V