ETHTE# 01- 5 - Q/9
NAME
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
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ADDRESS
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NAME OF MOBILE HOME PARK OR S/D
PHONE # ?lq- V'~-iq NAME OF OWNER (IFDIFFERENI) fflaa2l~ Noil<e r'
ADDRESS OF OWNER (IFDIFFERENI) "4 70 "I l&i- ~Cf , B rlt7 t e Lxo-_ l
PROPERTY LOCATION: STATE ROAD NAME AND 1V[, j a 5 ,5;~C1,
PURPOSE OF INSPECTION:
The aforementioned site has been evaluat y- tie Aameo'un y Health Department
Environmental Health Section, At the time of inspection, there appeared to be a septic
system serving this site. If this system should malfunction, the owner Is responsible for
any necessary repairs.
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
Signature of
/i /0~
Date