ET RHARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME C. 11 r V5 PHONE # l - /
ADDRESS -_LQ AA c; Z7rr6-7
NAME OF MOBILE HOME PARK OR S/D A
NAME OF OWNER (IFDIFFERENT) ! c` L
ADDRESS OF OWNER (IFDIFFERENT) ,tl.0 Z al
PROPERTY LOCATION: STATE ROAD NAME AND # LT& /cf3S
PURPOS4 U. 'INSPECTION.- �►-
t�.a ° =K�w
THIS INSPECTION IS VOID IF:
(1) the intended use of the septic system should change, and/or
(2). system should fait or malfunction, and/or
(3) the owner or tenant of the property changes, and/or
(4) after six months
AUTHORIZATION OF EXISTING SYSTEM
Si' ' ure of Environmentd
Health Specialist
0
Date