ETHTE# & - 6- - 87f4
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME" flt��f� PHONE #,29 •��y
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NAME OF MOBILE HOME PARK OR S/D W z:; d 12o, -,k /vC /+/6
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IFDIFFERENI)
PROPERTY LOCATION: STATE ROAD NAME AND # ;5?�1?5r
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 MUST BE 5' FROM ANY PART OF SEPTIC SYSTEM
DO NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
G.-- 05-ep� / -Z6 9G
of Environmental Health Specialist Date