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AUTHORIZATION NOTICE <br /> (Supplemental Form) <br /> <br />In ~rder t~ properly evaluate your existing sewage system, <br />information will be necessary: <br /> <br />the following <br /> <br />If your sewage system is:les__s than five (5) years old, and we <br />have zul approved record of the syst~, we can proceed without <br />~lg further action on your part. <br /> <br />If your sewage system is les__s 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 more than five (f) years old or has not <br />been pumped within the last five years: <br /> <br />a. You must have the septic tank pumped. <br /> <br />Have the septic tank pumper complete the form below. <br />A field visit will be required by the Sanitarian t.o <br />verify the location and condition of the septic system <br />If you have proof that your septic tank has been <br />pumped within the last five (5) years, sections a & b <br />will not be required. <br /> <br />COMPANY NAME: <br /> <br />PROPERTY OWNER: <br /> <br /> -For~ept~¢ Tar~kPumper Use Only- <br />Mike's Septic Service, Inc <br /> <br /> Pat Music <br /> <br />DEQ LICENSE NO: <br /> <br />ADDRESS WHERE TAN~ PUMPED: <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR ELBOWS IN PLACe? <br /> <br />IS DRAINFIELD BACKING UP INTO TANK? <br /> <br /> If gas, explain; <br /> <br />5721 ~illage View <br /> <br />Aumsville Oreqon <br /> <br /> gallons <br /> <br />  <br /> . YES; <br /> ~YES; <br /> <br /> YES; <br /> <br />NO <br /> <br />33519p~.2 <br /> <br />Rev. <br /> <br />DIAGRA~ OF HOUSE AND <br />LOCATION OF T;2VK: <br />EXA~fS LE : <br /> <br />Septic Ta~k <br /> <br />SIdNATURE OF PUMPER: <br /> <br /> DATE: <br /> <br /> <br />