ETHTE# 1--S-'4Ig63
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAMEh✓ �d�� PHONE # %ib (/L5 - 6096
ADDRESS 301 ia,s,,C9�du Sre /30 �trcJcPfv �G• 2�3d�
NAME OF MOBILE HOME PARK OR S/D 5 Ctx12-
NAME OF OWNER (IFDIFFEREN7) 44,U�7-
ADDRESS OF OWNER (IF DIFFERENT) �Z`f � P+� 142
PROPERTY LOCATION: STATE ROAD NAME AND # . �2 /YVA Vex -. '
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 BP 5'.FROM ANY PARTOE SEPTIC SYSTEM;.
a , as NOT DRIW-OR PARK ON� SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist Date