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Mario~ Court <br /> O ~ ~ a o N _t.y ON-s~E $~WAOE <br /> SEPTIC ~K P~ ~ ~SPEC~IOH FO~ <br /> <br /> 'The following retirements apply to ~he evaluation of an existing <br /> sewage .system. Please select the appropriate sea=ion and fellow the directions <br /> your ~,wa~e system is less than ~ive (Si' y~ar, o~d and a <br />~~tifleate ~f Satisfactory temple=ion has been issued for the <br /> ~x ~,,~ ~tem, the s~ptic.~ank does ~Ot ~e~ire pumping at this time. <br /> U~ ~ 8 }~ field ins~ction w~l be made of the entire system and a report <br /> will be i~sued.' <br /> ~AR~0N <br /> 00~ If your sewage Syst~ is ~re than ~ive (5} years old and <br /> 8U~tU~NG [NSP~[0Nsepti= :ank ha~ not' b~n pumped within the last five (5) years, <br /> follow the direo~ions DelOW. If you have proof that the septic <br /> tank has been pum~d within the last five (5) years, sections <br /> and (b) will not be <br /> a. The septic tank mugt be pum~d by a D.E.Q. licensed septic <br /> <br /> A field inspection will b~ re, ired by our on-site staff to <br /> verify the location and condition of the septic system. <br /> <br />~C15-S19 <br />!~E'V 3,0-92 <br /> <br /> *for septic pumper use only* <br /> (please print) <br /> <br /> PROPER?Y OWNER; <br /> <br /> APPROXIMATE SIZE OF TANK: ~(2~ ,gallons <br /> SEPTIG TANK MATERIAL= Concrete__; Steel, ~ ; Other <br /> <br /> Is TANK IN GOGD CONDITION? ............. Yes ~; Ne <br /> <br /> If "~e', explain: <br /> <br />~ INLET & OUTLET FITTINGS IN PLACE? .. Yeg /~'; Ne <br />IS DISPOSAL FIELD BACKING INTO TANK? ... Yes ; No 7~ <br /> If "Yes", e~plain: <br />DIAGP3U~ OF HOUSE, AND SEPTIC TAMK= (show detail with me&suremeDt~) <br /> <br />220 High St. NE · Salem, OR 97301~36~'0 <br /> <br />DATE OF PUMPING <br /> <br />SIGNATURE OF PUMPER <br /> <br /> <br />