ETApplication # Z(D
Harnett County Central Permitting
PO Box 65 Llllington, 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 A/m ['LddY1iL Date_La/
Address .D 6' rk 11"D
Telephone qtb - u2q
Property Owner
Lot Address -~Qls c J I
Name of Park ok- s
Parcel d "l
SW DW TW
Power Companyl
p><` Der-1 VS Phone III y -'te'a. -
-rrAA Lot Number f
~Z 2 PIN - Qi?~
(Size JL4_x'90 ) # Bedrooms YearqW0
'Y6:RQ2 VJ(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 is corr~ct -AL
Signature of owner or authorized agent
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Ex sting System (0- lq-l (
A"i
nature of Environmental Health Specialist i a e
SEPTIC ) 7. b O
6 111
4/08
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