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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME 00 PHONE #' LQ
ADDRESS ���/G D�+Jo 111Py !/a F c t� /li C • Z jd3
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7) L4 -..JE
ADDRESS OF OWNER (IFDIFFEREN7) P-0 • 13ZZZ7 C.{E:Jcr/1"C 11S�l�
PROPERTY LOCATION: STATE ROAD NAME AND # '5; t(3 i0 /niZ
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
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist Date