ETHTE#
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME '' PHONE # i4�- ViZ
ADDRESS Z yd s" Agl& &sue A��- &C jLder-rk LjYC_ zv74"v
NAME OF MOBILE HOME PARK OR S/D N e-r�
NAME OF OWNER (IFDIFFEREN1)
ADDRESS OF OWNER (IFDIFFEREN1)
PROPERTY LOCATION: STATE ROAD NAME AND # 6 /1139 !�
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
BUILDING-MUST BE FROM •
D NOT DRIVE PR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
Signs re of Environmental Health Specialist Date