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HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME ,12 f. / ;' PHONE #
ADDRESS? 6. (36x ZoS`7 14-,,jS-e� iU -C- Z'i 5-6,f
NAME OF MOBILE HOME PARK ORS/D
NAME OF OWNER (IFDIFFEREN7) ¢
ADDRESS OF OWNER (IF'DrFFEREN7) l f t c1 L s l v� #J -C- 77 -,75 -Zi
PROPERTY LOCATION: STATE ROAD NAME AND #', 55 -
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
BU
• -� •, •KNOT DRIVE OR PARK ON SEPM SYSTEM"
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist Date