ETHTE# —S ^ yLtL 01
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME �5PrWW —A 4-Shevk4 1+&VVA-d PHONE#
ADDRESS
NAME OF MOBILE HOME PARK
NAME OF OWNER (IFDIFFEREND
ADDRESS OF OWNER (IFDIFFEREND
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
AUTHORIZATIO OF EXISTING SYSTEM
F -!
of Environmental Health Specialist Date