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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HA.RNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME JA b~LS
PHONE # 9/0 - (v ~S- q q V ~
ADDRESS q 70 VYOA C k) U j
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IF DIFFERENI) &ry--Oa.Ve
ADDRESS OF OWNER (IF DIFFERENT) GdJ-Y'~
PROPERTY LOCATION: STATE ROAD NAME AND
PUXPOSE OF INSPECTION:
The aforementioned site has been eva uat y t e acne Zo-u-ntyRe--affh Department
Environmental Health Section. At the time of inspection, there appeared to be a septlc
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
1.
Signature of
AUTHORIZATION OF EXISTING SYSTEM
'Yr
l0/i3
Date