ETHTE# �30Y 2
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME (- �-J�OS PHONE
ADDRESS y( n=► FS�5� �' V /`j�C . ZZ5"Z�
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENT)
ADDRESS OF OWNER (IFDIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND #
system s�rnn t�iis side, (ftbi sxs err s aiuf� r a�fili ct�or t the o�rner 'iespansible foi
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
ks
BUILDINGMUST BE, 5'- FROM ANY PART OF •
i •
NOT DRIVE.OR PARK ON SEPTIC SYSTEMI,—
AUTHORIZATION OF EXISTING SYSTEM
of En
Health Specialist
/O -/d
Date