ETApplication # 11- 5 0 01 2. C-121
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Pax 910-893-2793
www,harnett.org/permits
Application for Existing Septic Tank in a !Mobile Home Park
Applicant Name: , len 111e_:51 Date: 3 r1
Address: AtlAfAl e-
Telephone: - 621
Property Owner: Agen 'hone: 1D a y 042q
Lot ,Address:
Name of Park: L03d Lot Number: /
Parcel: 0 59B, cLlv2- PIN.
/ SW # TVA (Size j,;~ X_Jo J # Bedrooms .3 ~ Year s
Power companyAtk =s&~~~~(For Progress Energy we need the premise number-)
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 til ation c rrect.
Signature of owner or authorized agent:
` AtY I e r
hr i ir. 19 2-5 gm :M e. le-
-TA rrd SEPTIC 4108