ETHTE# /41- 5 =_5Yf 73
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME ` _-5iZ?hVU�u / % ®.¢�� PHONE #
ADDRESS 28S �.�.., S s ry
NAME OF MOBILE HOME PARK OR S/D Z o
NAME OF OWNER (IFDIFFERENI)
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND # _5't/gzA
TRIS INSPECTION IS VOID IFs
(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
BUILDING
OF SEPTIC'
SYSTEM
1 ! t -PARK ON SEPTIC SYSTE
AUTHORIZATION OF EXISTING SYSTEM
24
i4da�ture of Environmental Health Specialist Date