ETHTE# 112— 369/ O
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME ' kb a�,`.4 L4�E PHONE# Z( Z—D76) Z
ADDRESS Dcl)UN N .C. 2,Yd33 q
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENI)
ADDRESS OF OWNER (IFDIFFERENI)
PROPERTY LOCATION: STATE ROAD NAME AND # 79, /YOL t4j a 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
BUILDING MUST BE 5' FROM ANY PART OF SEPTIC SYSTEM
DO NOT DRIVE OR PARK ON SEPTIC SYSTEM:
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist Date