ETHTE# I(e'-.z�378SD
NAME
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
PHONE # -6;?o7
ADDRESS
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7) C-rj�l', ffc(
ADDRESS OF OWNER (IF DIFFEREN7) 33Y re, 27 la(,r/ -%�G _ 273"YG
PROPERTY LOCATION: STATE ROAD NAME AND # ,3,_ I43S tz-,)
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
LIM
- / -/C,
of Environmental Health Specialist Date