ETHARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME M tan) 1 i PHONE #
ADDRESS L��4,j
NAME OF MOBILE HOME PARK OR S/D ox ea w
NAME OF OWNER'(IFDIFFEREVT) (' J/*-;
ADDRESS OF OWNER (IFDIFFERENI) RQ.,6jx 2� /
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
BUILDINGMUST BE 51 FROM A. N.Y'PA.RT'O,F SEPTIC SYSTEM.
OR PARK ON SEPTIC., SYSTEM
NOT DRIVE
AUTHORIZATION OF EXISTING SYSTEM
C_
of Environmental Health Specialist
Date