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Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793 `Q- f
www.harnett.org/permits
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Application for Existing Septic Tank in a Mobile 1 11a *44w1(.
Applicant Name: ',•,rt, ' W J. r Date: -7 l! t
Address:` ( lye ,erc~~
Telephone: ct,1 °i 434- _ g-73 11
Property Owner: Phone:
Lot Address: y +acc. R~ t Wrll t Sc-7r~M~-; _ r . -7
Name of Park: s ° a AH P Lot Number:
Parcel: d b PIN: -1" j l7l~b
SW DW TW (Size j 4-_x -'7 (o ) # Bedrooms ~ Year _L
9 1¢
Power Company: off, (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
L'N er b eta 91t ,
--Pat. 40 V wit' .1.-•
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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 correct.
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Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
7-
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gnature of nvrronmental Health Specialist Date
SEPTIC
4/08