ETd _ Application # 15 a oQ'2
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
Applicant Name: t.~- 4.,.- r ice) y- Date d
Address:
Telephon(
Property Owner: / t'' " "`C r Phone: 2171- S-1 1'
Lot Address: 1-61 tiCIDe Al 1 ~
Name of Park:
Lot Number:
Parcel: t~ ()U E; I Q D 13 PIN: fit a w l - .3 C 5 q- o[1 a
SW DW TW (Size 14 x_ _f'71 ) # Bedrooms Year (ei` 4
Power Company: (For Progress Energy we need the premise number.)
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 in mati n i orree
Signature of owner or authorized agent:
DO NOT SIGN BELOW - FOR OFFICE USE ONLY
Authorization of Existing System
Signature of Environmental Health Specialist Date
SEPTIC
Cave-F`c~ l~ 1 4101
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