ETApplication # _ l
f M Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
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www. harnett.orglpermits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name: rk r ;,t'c • , ~c'1 Date: / - l
Address: 27~r,
Telephone: _ i Email:
Property Owner: rtir.., - r- CkVK Phone: _ ft"` f"
Lot Address: 5"G- )?164,"1A%' L h..
Name of Park:_ Lot Number: .5 1 --N
Parcel: 0 1 E-7 k o l i PIN:~`7--f>C)
SW \ADW TW (Size -L x 6-:2.) # Bedrooms: Year:
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from Lillington:
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.
Signature of owner or authorized agent:
T~
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
n° uthorization of Existing System
Signature of Environmentae h Specialist A4aLte-
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