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AUTHORIZATION NOTICE <br />(Supplemantal Form) <br /> <br />In order to properly evaluate your existing sewage aystem, the following <br />information ~;ili be necessary: <br /> <br />rf your sewage system is l~ss than five (5) years old, and we <br />have an approved record of the system, we can proceed without <br />any further ac=ion on your part. <br /> <br />If your sewage system is less than five ($) years old, and we <br />do not have a record of an approved installation of the system: <br /> or; <br />If your sewage system is more than five (S) gears old or has not ' <br />been pumped within the las= five years: <br /> <br />a. You must have the septic ta~k pumped. <br />b. Have the septic tank pumper complete the form below. <br />c. A field visit will be required by the S~itari~-~ to <br /> verify the location a~d condition of the se~tio system. <br />d. If you have proof that gout septic t~nk has been <br /> pumped within the last five (5) years, sections a & b <br /> will no= be required. <br /> <br />COMPANY NAME: <br /> <br />PROPERTY OWNER: <br /> <br /> -For Septic Tank Pumper Use Only- <br /> <br />Mike's Septic Service Inc DEQ LIC~NS~ NO: ,31~q~D~? <br /> <br />John Miller <br /> <br />9832 Jordan St SE <br /> <br />gallons <br /> ,~, ,YES; <br /> <br />NO <br /> <br /> Salem Oregon <br />A~ROXIMATE SIZE OF SEPTIC TANK: /~ <br />iS TANK IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR ELBOWS IN PLACE? <br /> <br />ZS DRAINFIHLD BACKING UP- INTO TANK? <br /> <br /> If yes, explain; <br /> <br />DIAGR;~1 OF HOUSE AND <br />LOCATION OF <br /> <br />ExA2~PLB: <br /> <br />6' ~ ,Septic Tank <br />,~.-¢-C , <br /> <br />Rev. 2/86 <br /> <br />SIGNATURE OF <br /> <br />DATE <br /> <br /> <br />