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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION?
NAME 6k797d o-) PHONE #
ADDRESS /V7 �:V4'j ,I INIA n Ik C, 79? -33C.4
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENI)
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND # 4
2siv mil '7 .�
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
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist Date