ET RHTE #: 14-5-34899R
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
1 *114 K2 110
Name: Grover D. Ellis III Phone #: 919-499-9901
Address: 2115 Cool Spring Rd. Sanford, NC 27330
Name of Mobile Home Park or S/D:
Name of Owner (if different): Grover D. Ellis Jr.
Address of Owner (if different): 17163 NC 27 West Sanford NC 27330
Property Location (State Road name and #): 27 West
Purpose of Inspection: replace home
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
FWJ WIR 1 01 INEWIN mmma
AUTHORIZATION OF EXISTING SYSTEM
2e=— ,16e ,�f 1 1 &,L-517
ignature of Environmental Health Specialist Date
Elm