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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME /(�o 1 7dO1S A). PHONE # 9Ig - X -7-7Z-7-7
ADDRESS Z 5 00 U' t o USS axr y AQW N
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENI) Cdjt22r- X60
ADDRESS OF OWNER (IFDIFFERENT) 3Sa /- rG4-/t 14b F✓. 'ALC.
PROPERTY LOCATION: STATE ROAD NAME AND #5:n qs-c
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
I HORIZATION
EXISTING SYSTEM
of Environmental Health Specialist Date