ETHTE#
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME ANU 17 10— -111� I
&;0-CV124,6 dbr /VC. C-f—C PHONE #,E/�' -
ADDRESS Zq7tf
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEP.EN7)
ADDRESS OF OWNER (IFDIFFERENI)
PROPERTY LOCATION: STATE ROAD NAME AND # 0
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
C (AWAIVU)-./l
of Environmental Health Specialist Date