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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME &rilr--1 d G �)A ( PHONE # -fl d - O68 -33��'
ADDRESS /4' d f 174015 Cl-UWC# 121� if V /J •C • 7,75-Z6,
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NAME OF MOBILE HOME PARK OR S/D (wtf -3 - NDVYP04'
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IFDIFFEREN7)
PROPERTY LOCATION: STATE ROAD NAME AND # ti Z/0
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
b6 NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist
_-7'` c.
Date