ETHTE# /S -- Z-- 37y-75—
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME &dj�r4,
,r
ADDRESS 5'Z 5✓r), ,,,,e,, 104y ¢ rT /cJsBlosJ 3e. iU C L73S
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7) - / dLiN Aje4/S
ADDRESS OF OWNER (IFDIFFERENT) JY7 lVe4ts
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
BUILDING MUST BE 5` FROM ANY PART OF SEPTIC SYSTEM
DO NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist Date