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Application
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: ff Dates Ili
Address:
Telephone:z -ti°t t
Property Owner:
Lot Address:
Name of Park:
.
one: f
9
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Parcel: q.-7 c PIN:
SW DW TW (Size 42 x_ 7 j # Bedrooms Year
Power Company fogreL5 A r zr 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 information orrect.
n .r
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
A thonzation of Existing System
'Signature of Environmental Health Specialist Date
01
SEPTIC