ETLr0G 2 ~
Application # !1 ,
Harnett County Central Permitting
PO Box 65 Lillmgton, NC 27546
910-893-7525 Fax 910-893-2793
www hamett org/permlts
Applicant
Address
Telephon(
Property Owner
Lot Address
Name of
a
SDI if V- , N C' QDES 1
Lot Number
"J an
Parcel O X16 Y2- V aii97-:~ PIN
SW DW TW (Size 3q x--'7n ) # Bedrooms Yea
Power Company (For Progress Energy we need the premise number)
Specific Directions to Job from Llllington
You signature below certifies that all above information is correct
Signature of owner or authorized agent K
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Ignature of Environmental Health Specialist Date
SEPTIC
Phone
4/08
Application for Existing Septic Tank in 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