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AUTHORIZATION NOTICE <br />(Supplemental Form) <br /> <br />~n order to properly evaluate your existing sewage system, th~'following <br />information will be necessary~ <br /> <br />rf your sewage system is less than five (5) years old, and we <br />have an approved record of the system, we can proceed without <br />any further action on your part. <br /> <br />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 system: <br /> <br /> or; <br /> <br />been pumped within the last five years~ <br /> <br />a. You must have the septic tank pumped. ,,.~. . ~ ~,~ <br />b. Have the septic tank pumper complete the form below. 1 ~" ~ '~ 1.~.,..~ <br />o. A field visit will be required by the Sanitarian to ~ <br /> verify the location and condition of the septic syste~, MARION COUNTY <br />d. If you have proof that your septic tank has been ~UI[~I~G INSPECT/ON~,., <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 />COMPANY NAMe: Stayton Septic Service <br /> <br />PROPERTY OWNER: Ma~o~ ~in~ <br /> <br />DEQ LICENSE NO: <br /> <br />3 4, 9A~ <br /> <br />ADDRESS WHERE TANK PUMPED: 11054 ,Mill....C,,reek Rd. <br /> <br />lumevil, l~ ~ Oregon 973~ <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: <br /> <br />1000 ~allons metal <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />IX YES; NO <br /> <br />ARE BAFFLES OR ELBOWS IN PLACE? <br /> <br />YES; NO <br /> <br />IS DRAINFIELD BACKING UP INTO TANK? <br /> <br />YES; XX NO <br /> <br />If yee, explain; <br /> <br />DIAGRam! OF HOUSE AND <br />LOCATJON OF TANK: <br /> <br />EXAMPLE: <br /> <br />Septic <br /> Tank <br /> <br />er. 2/86 <br />umb <br /> <br /> <br />