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HARNETT COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH
307 CORNELIUS HARNETT BOULEVARD
LILLINGTON, NC 27546
EXISTING SEPTIC SYSTEM INSPECTION
NAME/,� �G P-.GGr PHONE #
ADDRESS �/d'Y /u �. � [_,a) C 27 ro y
NAME OF MOBILE HOME PARK OR S/D
NAME OF OWNER (IF DIFFERENT) n.�r rf [� D/t , A".AL or�yj,� d �4,-
ADDRESS OF OWNER (IF DIFFERENT) Z
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PROPERTY LOCATION: STATE ROAD NAME AND # �'t /76J /Desk -4-6 ., e l.A
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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
DO NOT DRIVE OR PARK ON SEPTIC SYSTEM
AUTHORIZATION OF EXISTING SYSTEM
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$efaJrre of Environmental Health Specialist Date