ETHTE# L .- � ; --3 26—L
HARNETT 'COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD `
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME ' ' c? LJ n,-j 66 h-1 PHONE # 44 5 _6*5
ADDRESS /5-Z Q. lZb f�G,�i{ 'c ., ,C— Z-715-01(
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IF DIFFERENT)
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND # zo fu/'r
PURPOSE oF 11YSPE TION�' G 2�
{r a �ca�uat, UP ! 8 ne ity
D @artmen�x
,: ` .. '" w. ai`l,.. z v" wY
w fin, r n ( c rr t ., , in p ctlo a e t`r�
11,..,
sys��r se�rrnng tii��t�� tt��s sys�te s�oul�t�i�lfi��ctor th�ow�ner is �espan��b�� for
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
n ure of Environmental Health Specialist Date