ETHTE#
HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME '' ic1 �e/�- ��i1�,6� l d12r PHONE # _)/1'- 777 -6,777
ADDRESS l —'l 2�4 ( o -7,(e o -5
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IFDIFFERENT)
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND #�
PURPOSE OFINSPECTTONE ''I SCJ ►'n !+
the afot lnentr he�sitth s heert a afuafq vt a arne a ea �y
p��.evan�61140-i
wy `!: ,rxz tu`tS" .r>unY
�nvir nmenta �e tr S ctrorr�, tt die rr � Lisp ct o , tl�er�appear'Od t6 b a s4pf!
system servinc, t it srtd, tfthii sys 6hr shod rialfurlctf di thiown p is resonsiv a foc.
p, +,
' �rax�r�ncessarearowq
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 -FROM PART OF
C SYSTEM
DONOT DRIVE OR PARK ON
C SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
C
of Environmental Health Specialist Date