ETHTE #: 13 -5 -31403
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
Name: Mike Clifford Phone #:
Address: 10028 Walter Myatt Rd Fuqua Varina NC 27526
Name of Mobile Home Park or S /D:
Name of Owner (if different): Christine DeLaCruz
Address of Owner (if different): 124 Tingen Rd Broadway NC 27505
Property Location (State Road name and #): Tin eg_n Rd
Purpose of Inspection: Garage (27'x28')
The aforementioned site has been evaluated by the Harnett County Health Department
Environmental Health Section. At the time of inspection, there appeared to be a septic
system serving this site. If the system should malfunction, the owner is responsible for any
necessary repairs.
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 change, and/or
4. after six months
1• 1% W,1 t
AUTHORIZATION OF EXISTING SYSTEM
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Signature of Environmental HeeSpecialist