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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXIS'T'ING SEP'T'IC SYSTEM INSPEC'T'ION
NAME /?'f 2jr e~ Ut PHONE # 77 d -
ADDRESS '2q~, t, ~4.CC,_ R-b r h`- . C 2:73,30,
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IF DIFFERENT) /Z /'6 --~s
ADDRESS OF OWNER (IFDIFFEREN7) i2dtaz.5 rlt; 4 !4> PM-f w C
PROPERTY LOCATION: STATE ROAD NAME AND # 6PQ-q6 / &M
THIS INSPECTION IS VOID IF:
(1) the intended use of the septic system should change, and/or
(2) the system should fail or malfunction,.and/or
(3) the owner or tenant of the property changes, and/or
(4) after six months
S7 EE 5,. F1®Nf` NY PART OF SEPTIGSYSTEM M
~TDR V4E~fPI~RK QN SPC SYSTEN~
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AUTHORIZATION OF EXISTING SYSTEM
-20-
Date
of Environmental Health Specialist