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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
INSPECTIONEXISTING SEPTIC SYSTEM
NAME
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ADDRESS
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NAME OF
MOBILE , / ,
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NAME OF OWNER (IFDIFFEREN7)
ADDRESS OF OWNER (IF DIFFERENT)
PROPERTY LOCATION: STATE ROAD NAME AND # Z5X,
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
BUI-LDINGIVIUST BE 5'FROM ANY PART OF SEPTIC'SYST'
EM
DON
• 1 PARK SEPTICSTEM
SigVature of En
AUTHORIZATION OF EXISTING SYSTEM
Health Specialist
Date