ETApplication # 2 7~ f
90
Harnett County Central Permitting
PO Box 65 Lllimgton, NC 27546
910-893-7525 Fax 910-893-2793
www harnett org/permits
Application for Existing Se tic Tank In a Mobile Home Park
Applicant Name r~~ A Date
Address Z
Telephone G 2 91~
Property Owner ~%V Phone
Lot Address
Name of Pa
Parcel 0
PIN
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 anon is correct
'~2 ex~~
Signature of owner or authanzed agent
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Xe " 7.11 t-O
agnature of 'Environmental Health Specialist Date
SEPTIC
4108
Ll)
Power Company (Far Progress Energy we need the premise number)