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HARNE T COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME 2,2,,,//_ 1 - x� PHONE # 9/" -66 2_ 8-S j J
ADDRESS i ���fir'Q)—Yo�r�(c� i/i, e (_i�y1� ✓� /,`;
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENT)
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND # °:tel Y4)ci 1- 1-�) oyv��
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
bd NOT DRIVE OR PARK ON SEPTIC SYSTEM,,,,,
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist Date