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AUTHORIZATION NOTICE <br />{Supplemental F~rm) <br /> <br />In order to properly evaluate your existing sewage system, the following <br />information will be necessary: <br /> <br />rf your sewage s~]stem is less than five ($) years old, and we <br />have an approved reco~d of the system, we can proceed without <br />any further action on your part. <br /> <br />If your sewage system is less than five (5) years old, and we <br />do not have a record of an approved installation of the system: <br /> <br /> or; <br />If your sewage system is more than five ($) years old or has not <br />been pumped within the last five gears: <br /> <br />a. You must have the septic tank pumped. <br /> Have the septic tank pumper complete the form below. <br />c. A field visit will be required by the Sanitarian to <br /> verify the location and condition of the septic system. <br />d. If you have proof that gout septic tank has been <br /> pumped within the last five ($) years, sections a & b <br /> will not be required. <br /> <br />Bev. <br /> <br />COMPANY NAME: <br /> <br />PROPERTY OWNER: <br /> <br /> -For Septic Tank Pumper Use Only- <br /> <br />Stayton Septic Service DEQ LrCENSE NO: <br /> <br /> Stayt0n Cooperative Telephone <br /> <br />ADDRESS WHERE TANK PUMPED: <br /> <br />APPROXIMATE S~ZE OF SEPTIC TANK: <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR ELBOWS IN PLACE? <br /> <br />8185 Anderson Rd. <br /> <br />Aumsville, Oregon <br /> <br />1000 ~atlons concrete <br /> <br /> XI YES; NO <br /> XI YSS; NO <br /> <br />34916 <br /> <br />IS DRAINFfELD BACKING UP INTO TANK? <br /> <br />YES; XX NO <br /> <br />If yes, explain; <br /> <br />2/86 <br /> <br />DIAGRAm! OF HOUSE AND <br />LOCATION OF TANK~ <br /> <br />EXAMPLE: <br /> <br /> Septic <br /> Tank <br /> <br />, St ret!4,, <br /> <br /> <br />