ET~',~pLL,•. Application it
Harnett County Central Permitting
PO Box 65 Liilington, NC 27546
Telephone Number 910-893-7525
. Fax 910-893-2793
Date:
Name:
Addre;
Telept
You signature below certifies that.ali above information is correc
Signature of owner or authorized agent:
t= -top
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Si store Environmental Health Specialist Date
Co,~f # I f 0792.
Application for Existing Septic System Inspection for a Mobile Home Park
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.