ETHTE# 3 �
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME 1 , I&7�M 7&.015 PHONE # /9 - !`- ,
ADDRESS /,,' A,J,u D� / di3 . C Z'1SZG9
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IF DIFFERENT) —M J
ADDRESS OF OWNER (IF DIFFERENT) ZV7 / e� 7` �.'. �; y• C Z'7
PROPERTY LOCATION: STATE ROAD NAME AND # .l''iAg "u j
PURPISE fJFl1V'PECTION 6�YL�
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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
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Sig ature of Environmental Health Specialist Date