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[ BUILDING ~NSe~C'nON ON-SITE SEWAGE SYSTEM <br /> 28`S CHURCH ,ST NE <br /> SALEM OR 97301 SEPTIC TANK PUMPING AND <br /> _.,,co. PH# (503)588-5147 <br /> <br />The following requirements apply ~a~on of an existing on-site sewage system. Please select the appropriate <br />section and follow the directions carefully. <br /> <br />1. 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 will 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 pumped within the last five (5) <br />years, (A) will not be required. <br /> <br />The septic tank must be pumped by a DEQ licensed septic tank pumper. <br />The septic tank pumper must complete the form below. <br />A field inspection will be required by our on-site staff to verify the location and condition of the septic system. <br /> <br />Company Name: <br /> <br />Property Address: <br /> <br />Property Owner: <br /> <br />Septic Tank Material: Concrete <br />Is Tank in Good Condition? Yes .,~ No <br />Are inlet & outlet fittings in place? Yes <br /> <br />Is disposal field backi.ng into tank? Yes <br /> <br />(~teel Other: <br /> <br /> __ If No, please explain: <br /> No <br /> No r~ If Yes, explain: <br /> <br />USE ONLY- -- <br /> <br /> DEQ License: . ;?~4 ~> <br /> <br /> Size of Tank: ./~,~ gallons <br /> <br />If an effluent pump is included as part of the septic system, the tank and pump assembly must be inspected and <br />cleaned when the septic tank is pumped. /~//¢' dosing <br /> <br />DIAGRAM OF HOUSE AND SEPTIC TANK. SHOW DETAIL AND MEASUREMENTS: <br /> <br />N <br /> <br />DATE/OF PUMCiNG <br /> <br /> F P U M¥:i~E~ MC15-S18/REV 4-96 <br /> <br /> <br />