ETHTE# 4 Z51
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME f� l C c�(%tj0 PHONE # �/�9 -��� -(,4B'
ADDRESS 6-w) /;ADo IF—V, A) . C a %75-2-6
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IF DIFFERENT)
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
AUTHORIZATION OF EXISTING SYSTEM
't'll C_ 14t3�
of Environmental Health Specialist Date