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(Supplemental Form) <br /> <br />In o~der to properly evaluate your existing sewage system, the following <br />information will be necessary: <br /> <br />rf your sewage system is ~ess than five (5) gears old, and we <br />have an approved record o'f the system, we can 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 no~ have a record of an approved installation of the system: <br /> <br />If your sewage system is more than five (5) gears old or has not <br />been pumped within the last five gears: <br /> <br />a. You must have the septic tank pumped. <br />b. Have the septio tank pumper complete the form below. <br />c. A field visit will be required by the Sanitarian ~o <br /> verify the location and Condition of the septic system. <br />d. If you have proof that your septic tank has been <br /> p~mped within ~he last five (5) years, sections a & b <br /> will not be required. <br /> <br />COMPANY NAME: <br /> <br />PROPERTY OWNER~ <br /> <br />ADDRESS WHERE TANK PUMPED: <br /> <br /> -For Septic Tank Pumper Use Only- <br /> <br />Stayton Septic Service <br /> <br /> Troy Lutz <br /> <br /> 6898 Sherman Rd. <br /> Aumsville, OR <br /> <br />DEQ LICENSE NO: <br /> <br />34,916 <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: 1000 <br /> <br />gallons concrete <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR ELBOWS IN PLACE? <br /> <br />IS DRAINFIELD BACKING UP INTO TANK? <br /> <br />YES; NO <br />YES; I~ NO <br /> <br />If yes, explain; <br /> <br />DIAGRAM OF HOUSE AND <br />LOCATZON OF T~¥K: <br /> <br />EXAMPL~: <br /> <br />Septic <br /> Tank <br /> <br />3/86 <br /> <br />SICNATURE OF pUMPER <br /> <br /> <br />