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Sn order to <br />information <br /> <br />AUT~ORIZATI~ NOTICE <br />(Supplemental <br /> <br />prop~rlw evaluate wour existing sewage system, the following <br />will be necessary: <br /> <br />Tf ~our sewage sWstem is less than fi~e (5) ~ears old, and we <br />have an a$$moved reco~d of the s~stem, we can proceed without <br />any further action on ~o~r part. <br /> <br />If Wour sewage sgstem is less than five (5) gears old, and we <br />do not have a record of an epproved installation Of the s~a=em= <br /> or; <br /> /~ ~our sewage system is mor~e than five (5) gears old or has not <br />been pumped within the last five Wears: <br /> <br />a. You must have the sest~c tank Dumped. <br />b. Have the septic tank p=raper complete the form below. <br /> A field visit will be required by the Sanitarian to <br /> verify the location and ~onditiOn Of the se$~ic s~stem. <br />d. If Wou have proof th&t W~ur septic tank has been <br /> pumped within the last five (5) ~ears, sections ~ & b <br /> will not be required. <br /> <br /> -For Septic Tank Pum~m USe Onlw- <br /> <br /> Stayton S~p%ic Service mE~ LZCENSE NO: 34916 <br /> <br />COMPANY NAME: <br /> <br />PROPERTY OWNER: <br /> <br /> , Wayne Brown <br /> ~'~64 Silver Falls }{wy .... <br />ADDRESS WHER~ TAN}f PUMPED~ <br /> <br /> Aums.v i .1..1..e.,......CE <br /> <br />~PROXZMATE SIZE OF SEPTIC TANK~ 1250 all~ns concrete <br /> <br />Is T~K IN ~D CONDITION? X~ YES; NO <br /> <br />ARE BAFFLES OR ELBOWS IN PLACe? <br /> <br />I~ DRASNFI~LD BACKING UP ~NTO TANI¢? <br /> <br />EX YES; NO <br /> <br /> ~X <br /> YES; NO <br /> <br />If 9es, explain; <br /> <br />DIAGRAM OF HOUSE AND <br />LOCATION OF TANK: <br />EXA~4PLE : <br /> <br /> 6' <br /> <br />$~GNATUPd~ OF PUMPER~ <br /> <br />Rev. 2/~6 <br /> <br /> <br />