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AUTHORIZATION NOTICE <br />(SjJpple~en~al Form) <br /> <br />In order, to properly evaluate your existing sewage system, the following <br />information will be necessary; <br /> <br />rf y~ur sewage system is less than five (5) years old, and we <br />have an approved recor'd of the system, we ca~ 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 ~our sewage system is more than five (5) years old or has not <br />been pumped ~ithin the last five years: <br /> <br />a. You must have the septic tank pumped. <br />b. 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 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 />ADDRESS WRERB TANK PUMPED:4~/~_~ ~;~I~ ~,~_~ <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />ARE BAPFLES OR ELBOWS IN PLACE? <br /> <br />IS DRAZNFIELD BACKING UP INTO TANK? <br /> <br />~allons <br /> ~'/YES; <br /> ~JYEW; <br /> <br />YES~ <br /> <br /> NO <br /> <br /> NO <br /> <br />/NO <br /> <br />pmh <br /> <br />DIAGRAM OF HOUS~ AND <br />LOCATION OF <br /> <br />EXAMPLE: <br /> <br />Septic <br /> Tank <br /> <br />2/£6 <br /> <br />X'_. ,/ <br /> <br />SIGNATURE OF PUMPER:_~ <br /> DATE: <br /> <br /> <br />