ET RHTE# D - 5013 =1 -1 j 69 R-
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME ~ (k~) UPC M 1 PHONE #
ADDRESS s ✓ 4r r-,, C, (~c( L I -x
NAME OF MOBILE HOME PARK OR S/D L,+ NAME OF OWNER (IFDIFFERENT) S~
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND # OA rr,~c r2
The aforementioned site has been evaluated by the Harnett County Health Department
Environmental Health Section. At the time of inspection, them 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
cr_
vironmental Health Specialist
Date