ETHTE# 15f - S --3ya n
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME �I Df+N l St r- PHONE # In-4q I -
ADDRESS A)
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND # S1- / 5"S'Z,
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
BUILDINGMUST E 5 FROM SEPTIC
T DRIVE OR PARK ON
AUTHORIZATION OF EXISTING SYSTEM
S' n ture of Environmental Health Specialist Date