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AOTHORIZATION NOTICE <br />(Supplemental Form) <br /> <br />In order to properly evaluate your existing sewage system, the following <br />information will be necessary: <br /> <br />1. If your sewage system is less than five (five) years old, and we have <br /> an approved record of the system, we can proceed without any further <br /> action on your part. <br /> <br />If your sewage system is less than five (5) years old, and we do not <br />have a record of an approved installation of the system: <br /> or; <br />If your sewage system is more than five (5) years old or has not been <br />pumper within the last five years: <br /> <br />You must have the Septic tank pumped, <br />Have the septic tank pumper complete the form below. <br />A field visit will be required by the Sanitaraian to verify the <br />location and condition of the septic system. <br />If you have proof that your septic tank has been pumped within the <br />last five (5) years, sections a & b will not be required. <br /> <br /> For Septic Tank Pumper Use Only <br /> dZ~-~D /~F~ ~ .~ /_ <br />COMPANY NAME: ~ ~-~- ~6~ ~3~ DEQ LICENSE NO: <br /> <br />ADDRESS WHERE TANK PUMPED: / '~ f~ 2 ~ K X/ ~0, ~.F. <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR ELBOWS IN PLACE? <br /> <br />~allons <br /> <br /> YES; <br /> YES; <br /> <br />IS DI%AINFIELD BACKING UP INTO TANK? <br />If ~, explain; ~'~.F~A~F~ /~ <br /> <br />NO <br /> <br />SEPTIC TANK MATERIAL: Concrete <br /> <br /> NO <br />YES; ~NO <br /> <br />Steel Other <br /> <br />DIAGRA~ OF HOUSEA~D <br />LOCATION OF TAN~: <br /> <br />BXAMPLE: <br /> <br />~ Septic Tank <br /> <br /> · Str~t ,, <br /> <br />3/82 Rev 10/87 <br />car <br /> <br />W <br /> <br /> <br />