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HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME LD a,� 9,te PHONE #
ADDRESS 6 Z
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENI) )/Xir/4*L. LJ cj,+br . bc)pr
ADDRESS OF OWNER (IFDIFFEREN7) 2531( NC -.S S k)
PROPERTY LOCATION: STATE ROAD NAME AND # _Mjs-y/� �n
PURPOSE O,FINSPECTION�` CZJ ���y vS6 T CB
T,,heaforementlthecCsitehs„beettevatuatedbyt a acne tiunl(
ea Department'
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Envlronmenta�eah Sctlorr: At theIM of Ispctlntl, therppeared tde a "septio;
S ystem serving tissit�. Ifthi system s�ioul�`trlalfunctltirt the owner fs'responsibte 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
BUILDING MUST BE 5' FROM ANY PART OF SEPTIC SYSTEM
DO NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist
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Date