ETHTE# - S- - 2167 b
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE # j/-0 -9 `3 - ZS7 /
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ADDRESS _ o , R3 l1 -Z -7 l
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7) ADDRESS OF OWNER (IF DIFFERENT) A -S A-b ~
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
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0 AUTHORIZATION OF EXISTING SYSTEM
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S ature of Environmental Health Specialist Date
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PROPERTY LOCATION: STATE ROAD NAME AND # :t iSS2