ETHTE#
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME 13J,r►L i3UZ f !�)e{>S (--f— PHONE #91
ADDRESS &16-) NC- 2i % (�O� A) -C, ?17S7Z/
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENI)
ADDRESS OF OWNER (IFDIFFEREN7) 9-7.1 7-r/SL.r.� pix, zevy
PROPERTY LOCATION: STATE ROAD NAME AND # -A�t-7310 i? tS(=A. 2= /1D
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