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AUTHORIZATION NL+Y'rCF <br /> (Supplomentil Form) <br /> .tr: order to propezly evaluate your exi:;Llrg :,Owage. syLLe.m, thv fo)1c,,,tru <br /> information will be necessary: . I <br /> 1. Ti your sewage system is less than five (5) ycaz s old, and wo <br /> have an approved record of the system, we ee•t proceed without <br /> any further action On your part. <br /> 2. If your ses.age system is less than five (5) nears old, and we <br /> do not h.ivc r; record of an aP1 rcv: d insCull:jLion of the <br /> Or; <br /> If your sewage system is more that: five (5) yeazs old ,,ir has not. <br /> been pumped within the: last five dears: <br /> a. You must have tie septic tank pumped. <br /> b_ Nave th•*, septic tank pumper complete the form below. <br /> c. A field visit will be required by the Sanitarian to <br /> verify the location and condition of the septic ystem, <br /> d. If yr u have proof that your septic tank has been <br /> pumped within the last five (51 years, sections a 6 b <br /> will not be required. <br /> -For SCptiC Tank Pumper U.3e Only- <br /> �+- �". . --_— <br /> COMPANY NAME: <br /> _�� DEQ Lrr�ems�� ra� 0- 4,lJ <br /> ADDRESS WHERE TANK PUMPED: < C 7,?-.".,. c.a,7 N <br /> 1 ApPROXIMATE $ZZE OF SE <br /> PTIC 7i TAN ._74 :2? gal loris <br /> IS <br /> TANK IN GOOD CONDITION? �' <br /> YES; ,0 <br /> ARE BAFFLES OR ELE0r5 XN PLACE? <br /> .. '1 y�sr _ MO <br /> %$ f R11IYFIEZ T} BACKING UP INTO TANIc? • <br /> YES; / N 'r0ix�rivrcl Z`ivLt yC'' <br /> fir, explain; C- r ,' Pse...r p� "°�' , /-ri . <br /> DIAGRAM OF HOUSE AND I `- -1LOCATION OF TANK: - <br /> EXAMPLE; <br /> k/0I-461 <br /> I U Sceptic Tank <br /> s .: S4___ ,_.— ► - <br /> SIGNATURE OF PUMPER: --1-,e2iedet--4.=,,---. <br /> t . 2/9E DATE: - C.,C' <br />