ETHTE#—S —' l q 6 Z
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE 6 �) Z4 Cc
ADDRESS /OQ
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENI)
ADDRESS OF OWNER (IFDIFFEREN7)
PROPERTY LOCATION: STATE ROAD NAME AND # lyt /V3 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 5' FROM ANY PART OF SEPTIC SYSTEM
NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
/q 6 - s --j
of Environmental Health Specialist Date