ETHTE# 1S --5-5G19 V
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME Coo( ?co [ 5 , N ,L, t�L PHONE # 7277
ADDRESS 2300 us
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENT) /'g "f /1 �o 7 ,
ADDRESS OF OWNER (IF DIFFEREN7) -
PROPERTY LOCATION: STATE ROAD NAME AND # _ 17c) 0�
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
BUILDINdMUS-
T OF SEPTIC'SYSTEM:
/ • f DRIVE •
AUTHORIZATION OF EXISTING SYSTEM