ETHTE# 1-A=� —� (i ( C j-�
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
tEXISTING SEPTIC SYSTEM INSPECTION
NAME c Y� // Gt/iYr� a f PHONE # 2 -Tj - Z 1
ADDRESS 2-,L1 DSy��.. /�'Ig� L�71 �✓ lV . C' ?/�S^? �,
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND # 6eq" l 3D 6A QJt)
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
cf�
of Environmental Health Specialist Date