ETHTE#
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE # 91j , 2,o
ADDRESS g9brLf C 2-75-6 �J
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENT)
ADDRESS OF OWNER (IF DIFFERENT) ,/t 75'exf
PROPERTY LOCATION: STATE ROAD NAME AND #
PURPOSE U INSPECTION• CZ}�f� 5i /1 u •,�
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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
AUTHORIZATION OF EXISTING SYSTEM
SIghature of Environmental Health Specialist
Date