ETH T E # 11-`j—�yZDg3
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME e55 -4G4 1.0d--&I�S _\ __ PHONE # C//O -
ADDRESS /24*rX C 7/ZS�y
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IFDIFFEREN7)
PROPERTY LOCATION: STATE ROAD NAME AND #-,'A 1 %D ,� ✓��e2
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
EXISTING SYSTEM
of Env-ironmentailiealrh Specialist Date