ETHTE# / V-- 5 - 3x"03
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME v L PHONE # /9--r5-7- ® 79
ADDRESS Zp (- G n; t e' G& --c )ZL V A) C
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENT)
ADDRESS OF OWNER (IFDIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND #,L1/Z. C
ZUa&hJ
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
i • NOT DRIVE OR PARK ON •
AUTHORIZATION OF EXISTING SYSTEM
Si ure of Environmental Health Specialist Date