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AUTHORIZATION NOTICE <br />(supplemental Form) <br /> <br />-In. orde~ to properly evaluate your existing sewage <br />information will be necessary: <br /> <br />system, <br /> <br />If your sewage system is less than five (five) years old, <br />an approved record of the system, we can proceed without <br />action on your part. <br /> <br />the following <br /> <br /> and we have <br /> any further <br /> <br />not been <br /> <br /> If your sewage system is less than five (5) years old, and we do not <br /> have a record of an approved installation of the system: <br /> or; <br /> If your sewage system is more than five (5) years old or has <br /> pumper within the last five years: <br /> <br />~/a. <br /> b. <br /> c. <br /> <br />You must have the septic tank pumped, <br />Have the septic tank pumper complete the form below. <br />A field visit will be required by the Sanitaraian to verify the <br />location and condition of the septic system. <br />If you have proof that your septic tank has been pumped within the <br />last five (5) years, scctions a & b will not be required. <br /> <br /> For Septic Tank Pumper Use Only <br /> <br /> ~ ~' ~o~? ~z//(~ DEQ LICENSE NO: ~ <br />COM~ANY NAME: . ~r~_~ <br /> <br />APPROXIMATE SIZE OF S~PTIC TANK: <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />gallons <br /> <br />/YES; NO <br /> <br />ARE BAFFLE~ OR ELBOWS IN PLACE? <br /> <br />/~/YES; NO <br /> <br />IS DRAINFIELD BACKING UP INTO TANK? <br /> <br />~O <br /> <br /> If yes, explain; <br /> <br />S~PTIC TANK MATERIAL: Concrete <br /> <br />steel <br /> <br />Other <br /> <br />DIAGRAI~OF HOUSE AJD <br />LOCATION OF TANK: <br /> <br />EXAMPLE: <br /> <br />Septic Tank <br /> <br />3~82 Rev 10/87 <br />car <br /> <br />X <br />well <br /> <br />W <br /> <br />SICNATURE OF PUMPER: <br /> <br /> DATE: <br /> <br /> <br />