ETHTE# - L— `�-- 3 36 1
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD`
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME Ili ' PHONE #- /6)
ADDRESS
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENT) TAo
ADDRESS OF OWNER (IFDIFFEREN7) -7 �3
PROPERTY LOCATION: STATE ROAD NAME AND # n -� i 6 �' 016
!'URPQS�D IN PECTIQN I'c ep
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system wing t� s� [ t �s sys ems s iaul� m I l cV�, R 0 Own �g respdn i�r� faf
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 ure of Environmental Health Specialist Date