ET RHTE# --57-3 077-1
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE # 77
ADDRESS
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7) Fh2921
ADDRESS OF OWNER (IFDIFFEREN7) Zyd3 6izun "1,6 ovW.J ' N• C
PROPERTY LOCATION: STATE ROAD NAME AND # N^ 1'13 1'—
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
SUILDING MUST 6E 5' FROM ANY PART OF SEPTIC SYSTEM
z. I70 NOT DRIVE OR PARK ON SEPTIC, SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
Sianaiure of Environ a tal Health Specialist
Date