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AU'II40RIZATION NOTICE <br />(Supplemental Form) <br /> <br />la order to properly evaluate your existing sewage system, the fo%lowing <br />information will. be necessary: <br /> <br />I.f your sewage system, is less than five (5) years old, and we <br />have a record of the system, we can proceed without any further <br />action on your part. <br /> <br />2. If your sewage system is more than five (5) years old or we. <br /> do not have a record of the system: <br /> <br />a, It will be necessary to have the septic tank pumped. <br />b. Have 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 tank has been <br /> pumped within the last five(5) years, sections a & b <br /> above will not be required. <br /> <br /> - For Septic Tank Pumper Use 0nly <br /> <br />COMPANY NAME. ~o (L · ,0// <br />PROPERTY OWNER: /~ ~ 7; ~[ ~ <br />ADDRESS ~ERE T~ P~ED: / / ~ /ff ~ <br /> <br />DEQ LICENSE NO:'3~--? '7 ~__~ <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR BLBOWS IN PLACE? <br /> <br />DIAGRAM OF HOUSE AND <br /> LOCATION OF TANK: <br /> <br />3/82 <br /> car <br /> <br />EXAY~LE: <br /> <br />f000 <br /> <br /> gallons <br /> <br />NO <br /> <br />SIGNATURE OF PUiMPER:f /Tf DATE: <br /> <br /> <br />