ETApplication # /i Z7 5-7-,6
Harnett County Central Permitting
PO Box 65 Ldlington, NC 27546
910-893-7525 Fax 910-893-2793
www harnettSorg/permits
Application for Existing Septic Tank in a Mobile Home Park
Applicant Name ~)a v Aop me r ~ 01,p. rg-n n'?-o Date G - _ I 1
Address i 4 a 11S'c~ ~
Telephone (~11 f3 y G
Property Owner -T- o Phone d 19) rl g 0- d 164
Lot Address c~ os-
Name of Park kpp o " Lot Number
Parcel 1~7 14-7 1 0/.,-/ PIN
-L/ SW DW TW (Size _ x Lo ti) # Bedrooms _ Year I CA
Power Company ~,~C WCq (For Progress Energy we need the premise number)
~ o9831
(9d
Specific Directions to Job from Llllington
151+
2 y o t bes,c le dL4,mrscvr 10 "A-h --V,e -tea +r~P5
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 SaJ.V",c A eg4L~L tAg r a/v~g,
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
TM t° Authorization of Existing System
ignature of Environmental Hea Specialist ate
g
SEPTIC 4/08
e