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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME /'1 P� C1�L�7c�J PHONE # i�
ADDRESS 36 z / VGl ti- W 00i r—Z7 la 2-7057
NAME OF MOBILE HOME PARK OR S/D fpd�%tis 6c A_ , 7
NAME OF OWNER (IF DIFFERENI) G%/�x Sv
ADDRESS OF OWNER (IFDIFFERENT) �/G /�� GKee (✓ �� �60* N.C.
Z 75-01
PROPERTY LOCATION: STATE ROAD NAME AND # i✓�y SS'
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`
as NOT DRIVE.OR PARK ON SEPTIC, SYSTEM' -
AUTHORIZATION OF EXISTING SYSTEM
zy
of Environmental Health Specialist Date