ETApplication # 11 1. rf f
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525 Fax 910-893-2793
www.harnett.org/permits
Applicant Name:
Address:
Telephone: -j - 2, - R0 , &7
Property Owner:
Lot Address:
Name of Park:
Paraei:
c3 rc d Phone: _ C4 1 0 - 9 `7 -
PIN:i .
SW DW TW (Size 14x ) # Bedrooms Year
Power Company: (For Progress Energy we need the premise number.)
Specific Directions to Job from._Lillinpton:
There Is a $100.80 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 informatio ',Is correct.
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
amzovK
SEPTIC
Date
Lot Number:
Environmental Hew-11th Specialist
L - r t
y
! feApplication for Existing Septic Tank In a Mobile Home Park