ETHTE# /5-5-3%6e2-
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE #
ADDRESS l¢ 2 �� N2� .5r /��cl� P�`> µ C-, 7
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7),
ADDRESS OF OWNER (IF DIFFERENT) 1S3y n/.0 C. 15-Z.j C�µ e L/
PROPERTY LOCATION: STATE ROAD NAME AND # DL15`tA Y&v. /t,D
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
DQ NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
Z
of Environmental Health Specialist
3 -00-/6
Date