ETHARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNIELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING S�E%PTI/C SYSTEM INSPECTION Q
NAME //SS U/L1CF�_ PHONE# J/�% -7o� Z. ZQZ�
ADDRESS W r,,.-)Zrrn_ r11tz -D/L (� U iy -C Z 7S2,(,,y
NAME OF MOBILE HOME PARK OR S/D _c,�,� ��,1�+ .�_���7✓—; C Z
NAME OF OWNER (IFDIFFEREN2) a5'fQ7, , ji�ldn�3E%l ({i/Zl�rtl V
ADDRESS OF OWNER (IFDIFFERENT) LON-$- �7v'' IU.C.
27�
PROPERTY LOCATION: STATE ROAD NAME AND # 5LI ti IS' I 13 U'II2t% t f2�
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
of Environmental
PING SYSTEM
/Z W-5
-23-/
Date