ETHTE# 5�=.5 / S
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME DRQ / PHONE
ADDRESS
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENI)
ADDRESS OF OWNER (IFDIFFERENI)
PROPERTY LOCATION: STATE ROAD NAME AND # yds
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'; FROM AN PART ,
F SEPTIC'SYS
DQ,'NOT DRIVE OR PARK ON SE y
AUTHORIZATION OF EXISTING SYSTEM
of Environmental
Specialist
, 14 y r,
Date