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BUILDING INSPECTION <br />285 CHURCH ST NE <br />SALEH OR 97Z01 <br />PH# (503)588-S147 <br />FAX~(503)588-7948 <br /> <br />,RECEIVED <br /> <br /> NOV t !996 <br />MARION C~ i ¥ <br />BUILDING INSPECTION <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 carefully. <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 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 verif7 the location and condition of the septic system. <br /> <br />..... FOR SEPTIC PUMPER USE ONLY ..... <br /> <br /> Stayton, Mill City & Silverton <br />COmpany Name: Sept ic Services DEQ License: <br /> <br />Property Address: 12053 Neal Street, Aumsville, Oregon <br /> <br />34916 <br /> <br />Property Owner. <br /> <br />Septic Tank Material: Concrete <br /> <br />Is Tank in Good Condition? Yes X <br /> <br />Are inlet & oufiet fittings in place? Yes <br /> <br />Alta & Robert Hollingsworth SizeofTank: 750 gallons <br /> <br /> Steel X Other: <br /> <br /> No If No, please explain: <br /> Lid of tank bent <br /> No X Baffle to dratnfield broken <br /> <br />Is disposal field backing into tank? Yes X No IfYes, explain: possibly need new leach lines <br /> <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 />11/11/96 <br /> <br /> DATE OF PUMPING <br /> <br />/SIG N,~I'UR EX~)F F~MPE FF' <br /> <br /> <br />