ETHTE# l � _--
HARNET'T COUNTY HEALTH DEPARTMENT
ENVJRONENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE # _919-572"y—,vi
ADDRESS 130 Jk;CkAV
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENT)
ADDRESS OF OWNER (IFDIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND #
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
LDINGMUST ;E 5'; FROM ANY PART OF
ii OT
'DRIVE OR PARK ON
AUTHORIZATION OF EXISTING SYSTEM
S° tore of Environmental ealth Specialist Date