ET RHTE# 11 - j _ 2 1 2 CHARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME PHONE #`/%!,3:50
ADDRESS C~t? !k=' Z~ i 1 X 0 1 0 _A5e 5 j
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IF DIFFERENT)
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND # Lj'
PURPOSE. _QE„INSPECTIONn
1'te aforementioned site has been evaluated by the erne oun y ea h.aepartment} +'F
Envirorimenta` Health Section: , t the,time of inspection,` there appeared to be aseptic
system serving this site If this system should 'malfunction, the ow.net, is responsibfb for a
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 5s FROM ANY'PART OF:SEPT(C SYSTEM
DO NO : DRIVE OR PARSON SEPTIG, SYSTEM ;
b r +.'r-a ek..~ r'
AUTHORIZATION OF EXISTING SYSTEM
IPA
re of Environmental Health Specialist Date