ETApplication # 11`500w24o(a3 _7
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546 t1
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant game: Date: J
Address:C^` l 1 l r l 2 Z 5►
Telephone: r
Property Owner: ARC Phone:` /L / 666
Lot Address: 11,5 D IAINe,
of Park: 7A q- Lot Number: 145
. y . x
Parcel: V),05 (o 2 PIN: 0557
__X_SW DW TW (Size x 'W_) # Bedrooms _ 7_ Year
Power Company: (For Progress Energy we need the premise number.)
f1 I s
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 agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
J~ )IT it
flI < ignature Environmental Health Specialist Date