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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME ' G, PHONE # r�
ADDRESS ZS' / n ' / ! of i7, -7 13 S-
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENT) �?,X
ADDRESS OF OWNER (IF DIFFERENT) %cis°"? 42.0
PROPERTY LOCATION: STATE ROAD NAME AND #
PURPOSE off` INS►PECT"ra�
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sYstetm snril thia 51 elt�s s sr1Floul� raluctwxkth o ner �s res 4nsibre for
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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
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BUI�.DINC NMC�Si` BE 5� f ROM ASV PART:OF SE�?Tf ' ' TEN {
`` �1G�T`RI�I OR,
PARK OIL SE PTIC SYS7E1
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AUTHORIZATION OF EXISTING SYSTEM
Sig " ure of Environmental Health` Specialist Date