ETHTE# 4/3100
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE#
ADDRESS C43 A� 6 �2-7,S7i,
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENI)
ADDRESS OF OWNER (IFDIFFEREN7)
PROPERTY LOCATION: STATE ROAD NAME AND # zie,2 03
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: BE 5' FROM ANY PART OF SEPTIC SYSTEM`:
b6 NOT DRIVE OR PARK ON SEPTIC SYSTEM
HORIZATION OF
3—/
of Environmental Health Sbecialist Date