ETHTE#
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME b 1 -,/an)FS PHONE#(X/g� VZ% 67Y5—
ADDRESS It S` Qk< bt},JG ✓, N' -C • Z -7
NAME OF MOBILE HOME PARK OR S/D %I /111 It, ia-1 _ G'sT 4r- 3
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IFDIFFEREN7)
PROPERTY LOCATION: STATE ROAD NAME AND #
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
BUIL
k_
AUTHORIZATION OF EXISTING SYSTEM
✓VI l �-�7S
of Environmental Health