ETHTE# 114 - -.3 S-0 306
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE # U/ -SO -2-_q13
ADDRESS
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7) �,� � / J��
ADDRESS OF OWNER (IFDIFFEREN7) & ZS-t>lo ;�hj / ry' /tt'C. 2,75-2 �.
PROPERTY LOCATION: STATE ROAD NAME AND # 2?cJY1Z t.1 1 L . l2I',
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
BUILDING
-UST BE 5' FROM ANY PART OF SEPTIC SYSTEM
DO NOT DRIVE OR PARK ON SEPTIC SYSTEM .;
AUTHORIZATION OF EXISTING SYSTEM
Sig ure of Environmental Health Specialist Date