ETApplication # 5-_?2~ Z-? 2 f
Harnett County Central Permitting
PO Box 65 Ldimgton, 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
A5hle
m Diw^
Date -7L/V/.1011
Address J U
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Av4
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Telephone
Property Owner ktyaWZ &P-Mir url Phone 4710' M-2c(1
Lot Address l ire( Dir VVW, o x_ 2933q
Name of Park 1 -IM Q ft134 YME TPQk Lot Number
Parcel &J2 /4 O'R da 29 PIN
✓ cSW DW TW (Size gx # Bedrooms 2 Year
Power Company rx~c~sz1~SS (For Progress Energy we need the premise number)
Specific Directions to Job from Lillinaton
1-0UAv✓ gxis To uwrr.1 -row LKFr A-r- WD #Nu- at 'RP Co f4Boo- 1:3 miLgs
-Axm-i.t izl&*T A -r A4t'R Avg --ma tA- L,FT csm tma- Pwr# RD,
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 abov orm s or ct
Signature of owner or authorized agent
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of
re of Environmental Health Specialist
g System
'fo `7--2' ~
Date
SEPTIC
4/08