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HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME 'Ra75.;,) r/.0 ;dr 1/5 PHONE #
ADDRESS S� v 11� l(S n _LST v C, 7-76Y&
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFEREN7) S
ADDRESS OF OWNER (IFDIFFEREN7) 7��1G_ CQ N,�,
PROPERTY LOCATION: STATE ROAD NAME AND # d2/YYd /�lrs+� �ow�✓�/CO
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
`', D0 NOT DRIVE OR PARK ON SEPTIC SYSTEM-
of
AUTHORIZATION OF EXISTING SYSTEM
Health Specialist
Date