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A~/TNORIZAT~ON NOTICE <br />(Supplemental Form) <br /> <br />In order to properly evaluate your existing-sewage aystem, the following <br />information will be necessary; <br /> <br />rf your sewage s~stem is less than five (S) years old, and we <br />have an approved record of the syatem, we can proceed without <br />any further action on your part. <br /> <br />If your sewage system is less than five (5) years old, and we <br />do not have a record of an approved installation of the system: <br /> or; <br />If your sewage system is mo~re than five (5) years old or has not <br />been pumped within the laat five years~ <br /> <br /> You must have the septic tank pumped. <br />b. Have the septic tank pumper complete the form below. <br /> A field visit will be required by the Sanitarian to <br /> verify the location and condition of the septic sFs=em. <br />d. If you have proof that your septic tank has been <br /> pumped within the last five (5) ~ears, sections a & b <br /> will not be required. <br /> <br />~For Septic Tank Pumper Use Only- <br /> <br />COMPANY NAME: Mike ' s SeD_tic Service. ~nG <br /> <br />DEQ LICENSE NO: 3351,9_D_2 <br /> <br />PROPERTY OWNER: Robert & Rachel Mus4~ ,. <br /> <br />ADDRESS WHERE TANK PUMPED: 230 Ccn%e~ .qt <br /> <br />APPROXIMATE SIZE OF S~I~TIC TANK: <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR ELBOWS IN pLACE? <br /> <br />IS DRAINFIELD BACKING UP_ fNTO TANK? <br /> <br />ga21ons <br />~ES; NO <br />~YES) NO <br />YES; ~/NO <br /> <br />If yes, explain; <br /> <br />DIAGRAM OF HOUS~ AND <br />~OCATION OF <br /> <br />EXAMPLE: <br /> <br /> Septic <br /> Tank <br /> <br />6 ' | <br /> <br />~'ICNATURE OF PUMPER: <br /> DATE <br /> <br /> <br />