ETHTE# /y
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME /1�i¢,,�G/� ]`zoc�lj�pc c,,CZ PHONE #2i % aI ZZ
ADDRESS z-Z Ket„ �J�C.;
NAME OF MOBILE HOME PARK OR S/D `7 C �,
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND #
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
D; "FROM
NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
v- o�
Sig9ture of Environmental Health Specialist Date