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AUTHORIZATION NOTICE <br />(Supplemental Form) <br /> <br />In order to properly evaluate your existing sewage system, the following <br />information will b~ neces~ar~ <br /> <br />rf your sewage system is less than five (5) uears old, and we <br />have an approved record of the system, we can proceed without <br />any further action o~ your par=. <br /> <br /> If ~our sewage system is less than five (5) weams o1~, and wu <br /> do not have ~ record of an approved installation of the system: <br /> Or; <br /> If gOut ~ew~ge System is m~re th~n five (~) gears old or has not <br /> bee~ pumped within the last five years: <br /> <br /> a. YOU ~ust h~ve the septic t~nk pumped. <br /> b. W&ve the septic tank pumper complete the fo~m below. <br /> c. A field visit will be required bg the Sanitarian to <br /> verify the luc~tiem a~d oon~i=ien of the seBtiu <br /> d. If you have proof that your septic tank has been <br /> sumped within the last five (S) years, s~ctions a & b <br /> will not be required. <br /> <br />............................... -For $~ptic Tank Pumper Use Only- <br /> <br />COMPANY NAME: <br /> <br />....... DEQ LICBNS~ NO: <br /> <br />PROPERTY OWNER: <br /> <br />~DDR~SS WHBRE TANK PUMPED= <br /> <br />A~PROXfMATE SIZE OF SEPTIC TAN~: <br />IS TAWK IN GOOD CONDITION? <br />aP~ BAPFLES OR BL~OW$ IN PLACE? YES; <br />IS DRAZNFI~LD BACKING UP INTO TANKF YES; <br />Zf gas, explain; <br /> <br />D~AGRAM OF HOUSE AND <br />LOCATION OF T$~K: <br /> <br /> 6' ~ Septic Tank <br /> <br />.... .~ ro~¢ <br /> <br />pmb <br /> <br />NO <br /> <br />~I(~NATUi~E OF RUMP~R: <br /> <br /> DATE: <br /> <br /> <br />