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AUTHORIZATION NOTICE <br />(Supplemental Form) <br /> <br />In order to properly evaluate your existing sewage system, the follo~ving <br />information will be necessary: <br /> <br /> 1. rf your sewage system is less than five (5) years old, ~w~ ~ ~.~ ~ ~ ~.,~ ~ <br /> have an approved record o~e system, we can proceed w~u~ <br /> <br /> 2. If your sewage system is less than five (5) years old, and we <br /> do not have a record of an approved installation of the sy~te~AR*ON <br /> o~; 5UILDING I~SPECTiOt,~ <br /> 32f your sewage system is more than five (5) years old or has not <br /> been pumped within the last five years: <br /> <br /> a. You must have the septic tank pumped. <br /> Wave the 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 system. <br /> d. If you have proof that your septic t831k has been <br /> pumped within the last five (5) years, sections a & b <br /> will not be required. <br /> <br /> -For Septic Tank Pumper Use Only- <br /> <br />p OpB T <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR ELBOWS IN pLACE? <br /> <br />gallons <br /> <br />IS DRAINFIELD BACKING UP INTO TANK? <br /> <br />YES; <br /> <br />NO <br /> <br />If yes, explain; <br /> <br />Rev_ 2/86 <br />pmk <br /> <br />DIAGRA~f OF HOUSE AND <br />LOCATION OF TANK: <br /> <br />EXA~]PLE: <br /> <br /> Septic <br /> Tank <br /> <br />6 ' ! <br /> <br />SIGNATURE OF PUMPER:~~ <br /> <br /> <br />