ETHTE# 11-5 _y Iq 4 f3
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME F'L/Le/% y/�i4f 1 �so/S PHONE# %/O
ADDRESS 3 o l Tawas Cn_. �i ( 5T£ 13z:) 2y -w`
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENI)�,yA)
-y'-
SO /J
ADDRESS OF OWNER (IF DIFFERENT)
231
Ste,
/3xzt k/ ( : r V . NX. . 2752`
PROPERTY LOCATION: STATE ROAD NAME AND # C—Poygj Lst x eB{e. �1
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
fHORIZATION OF EXISTING SYSTEM
SYSTEM;,
M.
9-5-/
of Environmental Health Specialist Date