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~ PUI~ER FORM <br />/~1 o~co~ o~-s~ s~ s~s~ JIl~ * ~11/I <br /> <br /> The followin ~quirements apply to the evaluation of an exis=ing on-~i~]O~l <br /> sewage system. Please select the appropriate section and foklow the <br /> carefully. <br /> <br /> PROPERTY ADDRESS: } ~O ~%~ Sr ~ r <br /> ~, + L~ <br /> <br /> If "No", explain: <br /> <br />ARE INLET & OUTLET FITTINGS IN PLACE? .. Yes__ <br />IS DISPOSAL FIELD BACKING INTO TANK? ... Yes <br /> <br />NO <br /> <br /> If '*Yes", explain: <br /> <br />DIAGRAM OF HO6~E AN~ SE~PTIC TANK~ (show d~tail ~i~ ~asu~men~s) <br /> <br />(503) 588-5!47 <br />(503) 588-7948 <br /> <br /> 713lg~ ., <br /> <br />SIGNATURE OF PUMPER <br /> <br />110 <br /> <br /> <br />