ETHARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME / i 5i,�tC 5-010 ;1,0(s PHONE # 1r;'5 95-1 700
ADDRESS SiaO8
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IF DIFFERENT) -::yUc
ADDRESS OF OWNER (IF DIFFERENT) iVl F, V, Z75'24,
PROPERTY LOCATION: STATE ROAD NAME AND #.5t
PURPOSE .U' INSFETZON 2 �{' 3 n cv�
arlludt
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�n l �fiea s P �a
r n enta
�i.,,,;�t� � ?1;�: 2"lla '�1'v 1��..u� v��; lia ��M� 1 ��y � �P 1�a,Y?.�.. lti o- a,��,t a�;`t�r, � as ,1,� � • „" n,t'�`�
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
Si ture of Environmental Health Specialist Date