ET RRHTE #��°
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME ! , < PHONE # 336p® 213 /Z 74,
ADDRESS
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IF DIFFERENT) -j
ADDRESS OF OWNER (IF DIFFERENT) `-to
PROPERTY LOCATION: STATE ROAD NAME AND # % Z 1
PURPOSE,IN PECTIN:
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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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AUTHORIZATION OF EXISTING SYSTEM
Si ure of Environmental Health Specialist Date