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AUTHORIZATION NOTICE <br />(Supplemental Form) <br /> <br />In order ~o properly e~aluate your existing s~w~ge system, the fo~loi~ing <br />information will be necessary: <br /> <br />rf your sewage system is less than five ($) years old, aud we <br />have an approved record of th~ system, we can proceed ~iTbout <br />any further action on your part. <br /> <br />If your s~wage system is less than five (5) years old~ and we <br />do not have a record of an ~pproved installation of the system: <br /> or; <br />IS ~our sewage system is moze than f~ve (5) years old or has not <br />been pumped within ~he last five years: <br /> <br /> 7ou must have the s~ptic tank pumped. <br />b. Nave the septic tank pumper complete the form below. <br />c. A field visit will be required by the Sanitarian to <br /> verify the location and conditio% of the septic system. <br /> If you have proof that your septic tank has been <br /> pumped within the last five (5) years, sections a & b <br /> will not be required. <br /> <br />-For Septic Tank Pumper Use Only- <br /> <br />COMPANY NAME: <br /> <br />Stayton Septic Service <br /> <br />~O tICE~$E No: D~9~6 <br /> <br />PROPERTY OWNER: Ji~ Fore~n <br />ADDRESS WHERE rANK PUMPEU:562 11th <br /> <br />Aumsville, Oregon <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK~ <br /> <br />~ O, O0 gallons concrete <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR ELBOWS IN PLACE? <br /> <br />IS DRAINFIELB BACKING UP INTO TANK? <br /> <br /> If yes, explain; <br /> <br />YES; <br />YES; <br />YES; <br /> <br /> NO <br /> <br />XX ~o both off. <br /> Lid is hole <br />~X No with large <br /> metal lid. <br /> <br />Rev. 2/85 <br /> <br />DTAGRAN OF HOUSE AND <br />[>OCA~ION OF lANK: <br /> <br /> ;XAMPLE : <br /> <br />Septic <br /> Tank <br /> <br /> <br />