ETHTE# 1-5= 4z/U3
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME 4,,,Cli PHONE# Si5-V7Z-V�ZD
ADDRESS
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IFDIFFEREN7)
PROPERTY LOCATION: STATE ROAD NAME AND # s/ %Y03 Q�
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
Bbil
of
JICISTBE 5' FROM ANY PART OF SEPI
NOi DRIVE OR PARK 09 SEPTIC SYS
AUTHORIZATION OF EXISTING SYSTEM
Intal Health Specialist
SYSTEM".
d >v -
Date