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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE # 9// S —9j;53 - .s (Zt
ADDRESS
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7) .¢Ur4.. , Le4-/h.6dze— i i2
ADDRESS OF OWNER (IFDIFFEREN7) V15 /%10a loo> /zo�z A)�C. Z-76V,I
PROPERTY LOCATION: STATE ROAD NAME AND # ;�rL tS�z 6441 Cn,� c «its
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
BUI(
MPTIC SYSTEM::
SYSTEM �';
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist Date