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AUTH6a~IZ&TION NOTICE <br />(Sapple~tal Form) <br /> <br />In o~der to properly evaluate ~our ~xisting s~wage system, ~he following <br />i~formation will b~ n~cessarN ; <br /> <br />rf yOUr sewage system is less than five (5) years old, a~d we <br />have ~n approved r~c~rd of the system, we ca~ proceeW without <br />any further act~ on your par~. <br /> <br />bee~ pumped within the las--~--~ive gears: <br /> <br /> A field visit will be req~red b~ the s~itari~ =o <br /> v~rifg the l~ation ~ ~n~ti~ ef ~he septic swstbm. <br /> <br /> pum~d within th~ las= five (5) gears, s~¢tions a & b <br /> will ~ot be required. <br /> <br />If ~;our s~wage =wstem is le$~s than fiv~ (5) ~ears old, and we <br />d~ mot h~ve a record of an ap$roved ~mstallation of the $Fstem: <br /> or; <br />If ~our $~a~e S~$tem ~s ~Or~ than five (5) ~ear$ old or has no~ <br /> <br />DE0 LICENSE NO: <br /> <br />CO~FANY NAMB; · <br /> <br />ADDRESS WNER~ TANK PUMPED: <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />AR~BAFFLES OR ELBOWS 1WPLACE~ <br /> <br />IS DRAINFIELD BACKING UP INTO <br /> <br />g~llons <br /> <br />YES; <br /> <br />If ~eS, explain;. <br /> <br />NO <br /> <br />DIAGRAms OF ~O~S~ AND <br />E X~P LE ~ <br /> <br />Rev. 2/86 <br /> <br /> <br />