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AUTHORIZATION NOTICE <br />(Supplemental Forl,) <br /> <br />In order ~o properl9 evaluate yo~z existing sewage system, <br />information wii~ be necessary: <br /> <br />Tf yOUr sewage system is' lcss th~_n five (5) gears <br /> <br />an~] further actio~ on your pa~t. <br /> <br />If your sei~age system ~s Jess than five (~) 9ears old, and w(~ <br />do not have a zeco~d of a~ approved ~nstallation o~ the syst:~ru: <br /> <br /> or; <br /> <br />been pn~U::~d within the last fiw? g~%aps: <br /> <br /> i'~uu :u~;t have ~he septic ~,a~k pu~ped. <br /> Ilaw: uho septic tank pumper ,~'o?pl~:~te th+~ kor~ beiow. <br />c. A field visit ~ill be rcqu:re~ bg the Sanitarian ~:o <br /> v~:rity the loc,etlon and condition of the septic system. <br /> I~ you have proof that your septic tank h~s been <br /> pumped w'it~]in thc lag~ five (5) ye~'$~ se:orions a & b <br /> will no~ be requircd. <br /> <br />PROPERT~ O~ER~ <br /> <br />ADDRESS WNERE TANK PUMPED: <br /> <br />-For Septic Tank Pumper Use Or~ly~ <br /> <br /> DEQ LICENS~ NO: ~' ~ ~ ~ / (~ <br /> <br />API~RO~¥IMATE SI2E OF ~EPTIC TAN~<: <br />IS ~ANK IN GOOD CONDITION? <br /> <br />ARE BAF?r,ES OR ELBOWS IN PLACE? <br /> <br />IS D~'A~NFIELD BACKrNG UP INTO TANK? <br /> <br /> :~ Wes, explain; <br /> <br />gallons <br /> <br />YES~ <br /> <br />NO <br /> <br />NO <br /> <br />i~rACPAM OF HOUSE AND <br />I, OCATION OT <br /> <br />EXAMP£D: <br /> <br />t22'- <br /> <br /> ......... ,~;t rar:t_ <br /> <br /> <br />