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fflar[on County <br /> <br /> ON-$XTE SEWAGE SYSTEM <br />SEPTIC TAN/{ PD-H~ING A~q) INSPECTION FORM <br /> <br />Site #: <br /> <br />~he 'following requirements apply to the evaluation of an existing on-sfte <br />'sewage system. Please selec~ the appropriate section and follow the directions <br />carefully. <br /> <br />If your sewage system is less than five (5) years old and a <br />Certificate of satisfactory Completion has been issued for the <br />~ystem, tbs septic tank does not require pumping at this time. A <br />field inspection will be made of the entire system and & report <br />will be issued. <br /> <br />If your sewage system is more than five (5) years old and the <br />septic tank has not been pumped within the last five (5) years, <br />follow the directions below. If you have proof that the septic <br />tank has been pumped within the last five ($) years, sections (a) <br />and (b) will not be required. <br />a. The septic tank must be pumped by a D.E.Q. licensed septic <br /> tank pumper. <br />b, The septic tank pumpe~ must complete the form below. <br />c. A field inspection will be rec~uired by our on-sAte staff to <br /> verify the location and condition of the septic system. <br /> <br /> *for septic pumper use only* <br /> (please pri.nt) <br /> Stayton/Mill City ~ Silverzon <br />COMPANY NAME: ...... CeDtic S.~rvices % D.E,Q. LICENSE #: 349_16_ __ <br />PROPERTY OwNER: Sheila Montgomery. <br /> <br />PROPERTY ADDRESS: 11555 McCellen Lane <br /> <br />Aumsville, Oregon <br /> <br />APPROXIMATE SIZ~ OP TA~K: .1000 ...... gallons <br /> <br />SEPTIC TANK MAT~RIA/,~ Concrete ..; Steel_X~ ; 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..~; No <br />IS DISPOSAL FIELD BACKING INTO TA~K? ... Yes. ; No X. ,, <br /> <br />If "Yes", explain~ <br /> <br />DIAGRAM OF ~OUSE AND S~PTIC TANK: (show detail with measurements) <br /> <br />[! <br /> <br />O~g COUNTY <br /> iNSPECTION <br /> <br />DATE OF PUMPING <br /> <br /> <br />