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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTIING SEPTIC SYSTEM INSPECTION
NAME C00//P(�j(�j(S 1J. C. Ur, PHONE# 9/9 —,,:p7 -7Z77
ADDRESS _ 236o 0/ �J S l / 1 / / /per.% /(% •C . Z i5az
NAME OF MOBILE HOME PARK OR S/D iTUieJ - 8
NAME OF OWNER (IFDIFFERENT) � %l^/
ADDRESS OF OWNER (IFDIFFEREN7)
PROPERTY LOCATION: STATE ROAD NAME AND # 571-1-76-3
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
a0 NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
of Environmental Health Specialist
Date