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MAR,ON COUNTY ON-SITE SEWAGE <br /> SYSTEM <br />BUILDING INSPECTION DIVISIOI~ I~~ ~/~ ~l~ .............. <br />3150 LANCASTER DR NE- SUi~ ~J ~b~/IU I AN~ HUMPING AND <br />SALEM OREGON 97305-1398 ~JUN 23 1997 INSPECTION FORM <br /> <br />The following requirements apply to the evaluation of an existing on-site sewage system. Please select the apprepdate <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, IA) will not be required. <br /> <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-sita staff to verify 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 <br />Property Address: 80[q q ~hou..t~ ~1, <br />Property Ownen Richard Hill <br /> <br />SepticTank Matedah Concrete X Steel <br />Is Tank in Good Condition? Yes X No <br /> <br />Are inlet & outlet fittings in place? Yes X No <br /> <br />Is disposal field backing into tank?. Yes__ No <br /> <br /> DEQ License: 3491 6 <br /> <br /> Size of Tank: 1 00 0 gallons <br />Other: <br /> <br />__ If No, please explain: <br /> <br />X . If Yes, explain: <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 />6/20/9? <br /> <br />DATE OF PUMPING <br /> <br />MC15-S 18/REV 4-96 <br /> <br /> <br />