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BUILDING INSPECTION <br />285 CHURCH ST NE <br />SALEM OR 9730! <br />PH# (503)588-5 ! 47 <br />FAX.,9(503)588-7948 <br /> <br /> ON-SITE SEWAGE SYSTEM <br />SEPTIC TANK PUMPING AND <br /> INSPECTION FORM <br /> <br />The following requirements apply to the evaluation of an existing on-site sewage system. Please select the appropriate <br />section and follow the directions carefl~lly. <br /> <br />If your sewage system is less than five (5) years old and a Certificate of Satisfactory Completion has been issued for <br />the system, the septic tank does not require pumping at this time. A field inspection wild be made of the entire system <br />and a report will be issued. <br /> <br /> If your sewage system is more than five (5) years old and the septic tank has not been pumped within the last five (5) <br />years, follow the directions below. If you have proof that the septic tank has been purn~in the last five (5) <br />years, (A) Will not be required. "~' --e,-~r~ ~ <br />A. The septic tank must be pumped by a DEQ licensed septic tank pumper. <br />B. The septic tank pumper must complete the form below. <br />C. A field inspection will be required by our on-site staff to verify the location and condition of the septic system. <br /> <br />..... FOR SEPTIC PUMPER USE ONLY ..... <br /> <br />Is Tank in Good Condition? Yes <br /> <br />Are inlet & outlet fittings in place? <br /> <br />Is disposal field backing into tank? <br /> <br />Company Name: C~'~ ~-e_~'~-~---~[~----C~_C_,-U~,~T DEQLicense: ~'~-~/ <br />Property Address: ~'(TLOL(' '~ ~..~J)'~. ~ ~t,~, ~ Y0 ,,3 r~ <br />Property Owner: F'4''~'c~''C~ ~ ~tJ ~--"~5 Size of Tank: /(:~ OO gallons <br /> <br />Septic Tank Material: Concrete ~ Steel Other: <br /> <br /> No If No, please explain: <br /> <br /> Yes ~ No <br /> Yes__ No ~: IfYes, explain: <br />If an effluent pump is included as part of the septic system, the dosing tank and pump assembly must be inspected and <br />cleaned when the septic tank is pumped. <br /> <br />DIAGRAM OF HOUSE AND SEPTIC TANK. SHOW DETAIL AND MEASUREMENTS: <br /> <br />N <br /> <br />DATE OF PUMPING <br /> <br />81~NATURE OF PUMPE~:~-- ' <br /> <br /> <br />