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AUTHORIZATION NOTICE <br />(Supplemental Form) <br /> <br />I~ order ~o properly evaluate your existing sewage system, ~he followin~ <br />information will be necessary: <br /> <br /> have an approved record of the system, we can proceed without <br /> any further action on your part. <br /> <br /> 2. If your sewage system is less than five (5) years old, and we~ <br /> <br /> ~ our sew~ e system is more than five (5) years old or has not <br /> been p~ped within the last five years: <br /> <br /> a. You must have the septic tank pum~d. <br /> b. Have the septic tank pumper complete the form below. <br /> c. A field visit will be required bw the S~itarian tO <br /> verify the location a~d condition of the septic system. <br /> If you have proof that your septic t~k has been <br /> pumped within the last five (5) years~ sections a & b <br /> will not be required. <br /> <br /> -For Septic Ta~k Pumper Use Only- <br />COMPANY NAME: Bob.'s San~,,~v Service. ~nc. <br />RR©PERTY OWNER: John Checkal <br /> <br />DEQ LICENSE NO: 11006 <br /> <br />ADDRESS WHERE TANK PUMPED= 13213 Brookside Drive, Al'oha, Or,~, <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR ELBOWS IN PLACE? <br /> <br />IS DRAINFISLD BACKING UP INTO TANK? <br /> <br /> If yes, explain; <br /> <br />1000 <br /> <br />gallons <br />~YES; <br /> ~. YES; <br /> <br />YES; <br /> <br />NO <br /> <br />DIAGRAM OF HOUSE AND <br />LOCATION OF TANK: <br /> <br />EXAMPLE: <br /> <br /> 6'~ Septic Tank <br />I22'- <br /> <br /> S.t~~t <br /> <br />kev. 2/86 <br /> <br /> <br />