ET RARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME 4- �l R PHONE # 3 r ? '
ADDRESS 7/�i lam✓ yC �i2�'
!IME PARK OR 1
NAME OF OWNER (IFDIFFERENT)
ADDRESS OF OWNER (IFDIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND #
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 -'NOT DRIVE OR PARK,ON SEPTIC SYSTE
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist
Date