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OREGON <br /> <br /> ON-SITE SEWAGE <br />TANK ~MPIN(~ AND INSPECTION FORM <br /> <br />The following <br />sewage System. <br />carefully_ <br /> <br />requirements apply to the evaluation of an existing on-site <br />Please select the appropriate section and follow the directions <br /> <br /> If your sewage system is less than five, (5) years old and a Certificate <br /> Of Satisfactory Completion has been issued for the system, the septic <br /> tank does not require pumping at this time. <br /> a, Authorization Notices do no.t require a field inspection of the <br /> system. A report can be issued based on a review of our files- <br /> b, Existing System Evaluations do require a field inspection of the <br /> entire system and a report will be issued. <br /> <br /> If you~ sewage system is m~ore t~an five (5) year._s old and the septic <br /> tank has not been pumped within the last five (5) years, follow the <br /> directions below. If you have proof that the septic tank has been pumped <br /> within the last five (5) years, section (a) will not be required. <br /> The septic tank must be pumped by a D.E.Q. licensed septic tank <br /> pumper. <br /> b- The septic tank purape~ mus~ co~plets the f~rm below. <br /> c. Authorization Notices and Existing System Evaluations require a <br /> field inBpeetion to verify the location and condition Of the <br /> septic system. <br /> <br /> *for septic pumper use only* <br /> Stayton/Mil]. City & Silverton <br />COMPLY N~I~E:_, ~qm~i~ ~q~Jf:.~ D.E.Q- LICENSE #: 34916,, <br /> <br />PROPERTY OWNER: Rodney A. & Maria E. Coakley <br /> <br />PROPERTY ADDRESS: 5785 Shaw Highway <br /> <br />Aumsville, Oregon 97325 <br /> <br />APPROXI~iATE SIZE OF TANK: 1000 gallons <br /> <br />SEPTIC T~/~K ~IATERIAL= Concrete~_~; Steel ; Other <br /> <br />IS TANK IN GOOD CONDITION? ............. yes X ; No <br /> <br />If "No", explain: <br /> <br />ARE INLET & OUTLET FITTINGS IN PLACE? .. Yes X ; NO <br /> <br />IS DISPOSAL FIELD BACKING INTO TANK? ... Yes ; No X <br /> <br />If "~es*', explain: <br /> <br />DIAGRAM OF NOUSE AND SEPTIC TANK: (show detail with measurements) <br /> <br />? <br />N <br /> <br />(503) 588-5147 Scnalor [luilding <br />~^x ($03) $88~7948 220 i-~igh st, NE ,~ Salem, OR 97301-]670 <br /> <br /> 1/17/94 <br />DATE OF PUMPING <br /> <br /> MCI!~-$19 <br /> REV 1/93 <br /> <br /> <br />