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AUTHORIZATION NOTICE <br /> .~ .- (Supplemental Form) ~_ f,~in~g ? ~/~i~ <br />In order to properly evaluate your existing ~ewage system, ~he fol~p~;'~ <br />information will be necessary:~f;~C;? <br /> <br /> 1. If your sewage sy$ce~ i$ less than five (5) years old. %~f~n~. <br /> have <br /> a record of the system, we can proceed wl~hou~ ~lS~U~Y~ <br /> action on yoor part~ "~ ~OP~/O~ <br /> If yOUg sewage system is more tban five (5) years old or we <br /> ~o nqi bare a record of tile system: <br /> <br />ay I5 will be necessary uo have the ~eptic tank pumped. <br />b, Have the septic tank pumper comp%ere the form below. <br />c. A field visit will be required by the Sanitarian to <br /> verify the location and condition of the septic sys~cra. <br />d. If you aave proof that your Septic tank has been <br /> pumped within the las: five(5) years, sections a & b <br /> above ~ill not be requirmd+ <br /> <br />For Septic Tank Pumper Use Only - <br /> <br />COn,ANY NAME: ~]t$,y_%~93/ Sep%Je Servj~Q~ ~ DEQ LICENSE <br />PI{OPER~ OWNER:~2' .q ' ~_ ~[.~,r ~ ...... ~ .-( ,:., ~..,~, <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: <br /> <br /> IS TANK IN GOOD CONDITION? ~ NO <br /> <br />g~g BAFFLES OR ELBOWS £N PLACE? ~; <br /> NO <br /> <br />DIACP~I~ OF HOUSE ~ND <br /> LOCATION OF TANK: <br /> <br />EXAMPLE: <br /> <br />7"--~Sep~ci t:an k' ...... <br /> :: ....... <br /> ,- .......... ' . <br /> '~ ; , <br /> <br />Ssllons <br /> <br />DATE: <br /> <br /> <br />