ETHARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE # f >Ds` • X4'7
ADDRESS 1-7Z
NAME OF OWNER (IFDIFFERENT)
ADDRESS OF OWNER (IF DIFFEREN7) 119 (
PROPERTY LOCATION: STATE ROAD NAME AND # /a
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
BtjILDINGMUST BE 5': FROM AN, YPART OF SEP ICIYSTEM..
KNOT DRIVE OR PARK ON SEPTIC, $YSTE
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist
Z -t -1 S —
Date