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AUTHORIZATI~q NOTICE <br />(Supplemental Form) <br /> <br /> order to properly evaluate gout existing sewage system, the following <br />informa:i~n will be necessary: <br /> <br />any further ac:iom on gout ~mt. <br /> <br />.do no.~ Dave a re~rd of a~ a~roved installation of the <br /> <br />If gout s~a~ s~Cem i~ ~se th~ fi~ (~) ~e~rs old or has <br />been' p~p~d within the iasc five gears: <br /> <br /> a. ~ou m~t have ~e S~pt~c t~k <br /> <br /> A field visi= will be required b~ ~e S~i=mri~ to <br /> verifW the lo=a~i~ ~d ~ndition Of the se~tf~ s~$tem. <br />~- If ~OU have pr~f that ~oUx septic t~ h~ b~ <br /> ~mped within the l~t fi~ (~) Wears, s~ioas a & b <br /> will no= be <br /> <br />COMPANY NA~E: Mike's Septic <br /> <br />P~.OPERF? OWNER: J~h~ Miller . <br /> <br />ADDRESS NH~R~ TANK PUMPED~ 9832 Jo~d&n St SE <br /> <br /> Salem Oregon <br /> <br />~$ROXIMA~ SIZE OF SEPTIC T~K: /~ <br /> <br />ARE ~AFFI. T$ OR ~I~OWS IN PLAC~P <br /> <br />IS DRAINFI~LD BACKING UP- ~NTO TAIVK? <br /> <br />If ges. explain; <br /> <br />DEQ LICENSE NO: ,3~KI~D_? <br /> <br />gallons <br /> <br />YES; <br /> <br />NO <br /> <br />LOCATION OF Z/,¥K: <br /> <br /> ~ $e~:,2c Tank <br />~, |, <br /> <br />DA T~ .. <br /> <br /> <br />