ETHTE# / a 3
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME
ADDRESS 00 i ®� e ? 33 V
NAME OF MOBILE HOME PARK OR S/D
NAME OF t, '_.�:
ADDRESS OF OWNER
PROPERTY LOCATION: STATE ROAD NAME AND # J 7 Q? >
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
AUTHORIZATION OF EXISTING SYSTEM
Sijjiature of Environmental Health Specialist Date