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MARION COUNTY <br />BUILDING INSPECTION DIVISION <br />3150 LANCASTER DR NE - SUITE C <br />SALEM OREGON 97:~05-1398 <br /> <br /> ON-SITE SEWAGE SYSTEM <br />SEPTIC TANK PUMPING AND <br /> INSPECTION FORM <br /> <br />The following requirements apply to the eveiuation ofen 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) ye~am 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. !f 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 vedfy the location and condition of the septic system. <br /> <br />FOR SEPTIC PUMPER*USE ONLY <br /> <br /> Stayton, M111 C.).ty, & <br />Company Name:Sllverton Sept ic SerYJ. ces DEQLicense: 34916 <br />Property Address: 11401 Sttenkamp Rd.' AumsYi. lle, Or 97325 <br />Property Owne~ W t 11 £ am Lo n[ Size of Tanl~ · 1200 gallons <br /> <br />Septic Tank Material: Concrete ~._~__ Steel____ Other:. <br />Is Tank in Good Condition? Yes X No_...~ If No, please explain:~ <br />Are inlet & outlet fittings in place? ' k(es X No <br /> <br />Is disposal field backing into tank? Yes ~ No X IfYas, explain: <br /> <br />If an effluent pump is included as part of the septic system, the dosing tank and bump 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 />.... ------,. <br /> S ~A¥ 2 8 t997 <br /> <br /> MARION COUNTY <br /> BUILDING iNSPECTION <br /> <br />$ <br /> <br /> Ua 28 1997 <br />DATE OF PUMPING <br /> <br />MCIS-S18/REV 4-96 <br /> <br /> <br />