ETHTE# 1-1 —5 --Li 15g--)
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME '' :7J O17� PHONE # Lj19 - 13-5�Y05�-
ADDRESS�oSS // v �e cs � 67.-L_ r✓, ALC. X76 1�
NAME OF MOBILE HOME PARK OR S/D V!C�,o- A%i` (s /P74 -,g7
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IFDIFFEREN7)
PROPERTY LOCATION: STATE ROAD NAME AND # 3Z/y,13 "eA--1609
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
bd NOT DRIVE OR PARK ON SEPTIC SYSTEM _
AUTHORIZATION OF EXISTING SYSTEM
,14 _ i 11-25�77,2�*5
of Environmental Health Specialist Date