ET RHTE#__3
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME JS. I o PHONE # / / _
ADDRESS 6z2 o Rcc
NAME OF MOBILE HOME PARK OR s/D
NAME OF OWNER (IFDIFFEREN7) 4
ADDRESS OF OWNER (IF'DIFFEREN7) , V t C Z117
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
R
BUILDING
FROM ANY PART OF SEPTIC'SYSTE'M::,
OQNOT DRIVE OR PARK ON SEPTIC SYSTE
AUTHORIZATION OF EXISTING SYSTEM
0
of Environmental Health Specialist
Date