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HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME b19-0;6 ! gg&ut f% AfY..a-. Z;OC- PHONE # 919 =465- -7.50i,9
ADDRESS
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENT) /' l" nil -) y- %7pr/Q J mik-J101C
ADDRESS OF OWNER (IFDIFFERENT) -72Y r i4b6w �21b
PROPERTY LOCATION: STATE ROAD NAME AND # 05 —Q Z- tZZ tp G7d�
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
AUTHORIZATION OF EXISTING SYSTEM
I74r'5?
of Environmental Health Specialist Date