ET RHTE# I U_!S-- S e 3 e A
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME 14- VT- / S" c�/oZ PHONE #
ADDRESS
NAME OF MOBILE HOME PARK OR S/D (G�Z 2 `--
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IFDIFFERENI)
PROPERTY LOCATION: STATE ROAD NAME AND # 6,^ CSL /3111 �,
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.
DQ NOT DRIVE OR PARK ON SEPTIC SYSTEM; ,
of
AUTHORIZATION OF EXISTING SYSTEM
Health Specialist
S -Y—/ 6
Date