ETHTE#
HARNETT COUNTY HEALTH DEPARTMENT
ENVJRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME I ,pow,,. PHONE #
ADDRESS tj L 7�
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IF DIFFERENT) ba4j mem
ADDRESS OF OWNER (IF DIFFERENT) 4C7 A) C S w
PROPERTY LOCATION: STATE ROAD NAME AND # jAd o _..
PURPOSE 4F�IN'PEC"Id11r. (--'
s stem semi Ih�i� �th;sYser svl` '�turctr tt� owner ass on6ibe for lr
i i�x 1.�.,.,taS3. ?;.,, a.. , , - ,,„ 1 .,'�' „�AFI '7{.4G •7.}(�� �,"�, 1: i��l ,.5' t''�' 1 �` �4t�`1. '� to ct,
+ i
�`,e1 h'i•. l ul a,as t' 1"a t".i.',�`ll �5
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
BULGING �5 SE 5, IRON ANY PART OF” SEPT SYSTEM �,
n \
D NEST DRIVE OIL N SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
ig t re of Environmental Health Specialist Date