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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME` ��1� �'f-� �/ PHONE #
ADDRESS -119 -5 / Z-7 —41/
NAME OF MOBILE HOME PARK OR S/D o.,V4 M/W Z
NAME OF OWNER (IF DIFFERENT)
ADDRESS OF OWNER (IF,DIFFEREN7)
PROPERTY LOCATION: STATE ROAD NAME AND #,V SZ I j(7v `Z4) .
PURPOSE QR' IN.PECTIONili
7e" Wil"DIR r is cif n bjt rte orueaepar AM
n ^�� 4' $ �4w4 �� kfup", 1� Fox
I�nrrr n e cfro►f f ir�� f o ft�aar�ed f a tr{
d �
i i �. 1 •y k F�. % 3' 4 L"u�,lt`a�' i\ e'Oa i�\ gyp;" \C
system aernn ' fi�srf� tthi� sysf� s�io�t �I��t�c����� t��;ovirrtor is �espansi��a fob
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
S' ature of Environmental Health Specialist Date