ET RHTE#
BARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME % b7- �'�s � _Lyc/ PHONE # Iq ZS J -66%Z
ADDRESS�&,Z AUbl jM Rd. - d, V. NC '27S�p
NAME OF MOBILE HOME PARK OR SID
NAME OF OWNER (IF DIFFERENT) i�— +- U (ori%(
ADDRESS OF OWNER (IFDIFFERENT) 12S 5.5 /NC - L? Z
PROPERTY LOCATION: STATE ROAD NAME AND # Al�, , ! Z ,
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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
SYSTEM.
AUTHORIZATION OF EXISTING SYSTEM
Health Specialist Date