ETHTE# ib -S -3 -ISS,
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME
ADDRESS
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENI)
ADDRESS OF OWNER (IF DIFFERENT)
PHONE# 57/0 —5-914 Zs!
PROPERTY LOCATION: STATE ROAD NAME AND # ` Q -7
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 T FROM ANY PART OF SEPTIC SYSTEM
aQ NOT DRIVE OR PARK ON SEPTIC, SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
3i . ature of Environmental Health Specialist Date