ET RH T E # /G - � - V61632
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE # 'J/C1-,Tt)$ - 3�
ADDRESS 6N 5n,m{GeT-, 72-�iL F-- l! . K. C_. 7i75�
NAME OF MOBILE HOME PARK OR S/D ,Iz� (LJ��,, Ute, -3`$
NAME OF OWNER (IF DIFFERENT)
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND # (iZ LQb 1 n)
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
Da NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health
-3 -l-7
Date