ETApplication # J 150 0;2 7 579 Ar
Harnett County Central Permitting
PO Box 65 Lillington, NC 27546
910-893-7525.Fax 910-893-2793
www.harnett.org/permits
Application for Existing Septic Tank in a Mobile Home Park / I
Applicant Name: RC~~k/i aftwff r-) Date: Z7/ I f
Address: qqLK) G chl(ch? Rd I I( log' 2
Telephone:
PropertyOwner: TMfy)Q ~ t a &Tonw e:
Lot Address: I LA c 5 Ise
Name of Park: C~. Lot Number:
Parcel: PIN:
SW DW TW (Size [7- x:70 ) # Bedrooms_ Year- 92
Power Company: (For Progress Energy we need the premise number.)
4
`1W - ~-A.~-~ -e5 p~~ VZ1- 0 t\.1-e-1
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.
CS
You signature below certifies that all above informati is corre .
Signature of owner or authorized agent:
1 DO NOT SIGN BELOW - FOR OFFICE USE, ONLY
Authorization of Existing System
T==:E-2 2JI44,-,~ A iu-ws 1-
nature of Environmental Health Specialist Date
SEPTIC., 4/08;