ETHTE#5=S - 35243
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
rIST N TRIC $ � TEM INSPECTION
NAME PHONE #
ADDRESS fib • fax /2a? e'y N �-Z,I 38 �P
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENI) 7Rv l V
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND # 15A-1 fa. Lj1 (a S:fj6 , 1, 1ee-
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
BUILDINGMUST BE 5" FROM ANY PART OF SEPTIC'SYSTEM,
01!1:t? NOT DRIVE OR PARK ON •
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist Date