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HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME Wr� 6,4' A Pn, -C -• PHONE # Z/
ADDRESS /00 Ley C.- r7 (/ y ZZ�2(i
NAME OF MOBILE HOME PARK OR S/D Cha 44 /9
NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IFDIFFEREN7)
PROPERTY LOCATION: STATE ROAD NAME AND # D
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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
BUI z GMUSTBE 5' FROM ANY PAR7`OFSEPTIC SYSTEN ,
p0"NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUT�H/ORIZATION OF EXISTING SYSTEM
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of Environmental Health Specialist Date