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AUTHORIZATJON NOTICE <br />(Supplemental Form) <br /> <br />In order to properly eval~ate your existing sewage system, the follorving <br />infor~llation will be necessary~ <br /> <br />rf your sewage system is less than five (5) years old, and we <br />have an approved reoo~d of the system, we can proceed without <br />any further action o~ yo~r parT. <br /> <br />If your sewage s~$tem is less than five ($) years old, and we <br />do net have a ~'ecord of an approved installation of the system: <br /> 0£; <br />If gour se~!7~ system is mo~e than f~ve (~) years old or has not <br />been pumped ~ikhin ¢he las¢ five yea~s: <br /> <br />a. YOU must have the sepuic tank p~mped- <br />b. Have the septic ca~k pumper complete the form b~lo~. <br />c. A field visit will be required by the Sanitarian to <br /> verifg the location and condition of the septio system. <br />d, If yo~ have proof ¢hat your septic tank has been <br /> pumped within the last five (5) years, sections a & b <br /> will not be required. <br /> <br />CON?AN? NAME: <br /> <br />PROPERT~ OWNER: <br /> <br />-FO~ Septic Tank Pumper Use Only- <br /> <br />DEQ LICENSE NO: <br /> <br />ADDRESS WHERE TANK PUMPED: <br /> <br />APPROXi'MATE SIZE OF SEPTIC TAN~: <br /> <br />gallons <br /> <br />SS TANK IN GOOD CONDITION? <br /> <br />NO <br /> <br />ARE BAFFLES OR ELBOWS IN PLACE? <br /> <br />YES; NO <br /> <br />IS DRAINFIELD BACKING UP IN~O TANK? <br /> <br />YES; NO <br /> <br />If yes, explain; <br /> <br />DIAGRAM OF HOUSE AND <br />LOCATION OF TANK: <br /> <br />EXAMPLE ~ <br /> <br />SIi~NATURE OF PUMPER: <br /> <br /> DATE: <br /> <br />Rev_ 2/86 <br /> <br /> <br />