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BUILDING INSPECTION DIVISION lC TANK PUMPING AND <br /> 3150 LANCASTER DR NE- SUITE C~,,~,,~ JUN2 1997~ <br /> o,,co, SALEM OREGON 97305-1398 INSPECTION FORM <br /> M^,,0, c0uNT q q - O q 5 I <br /> ~-"J ~" ~ :.:: :.'3. <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 oft. he entire system <br />and a report will be issued. <br /> <br />If your sewage system is more than five (5) years eld 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 />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 /> Stayton/Mill City & Silverton <br />Company Name: Septic Services ,.. DEQ. J. icense: 34916 <br /> <br />PropertyOwnen Richard Hills SizeofTank: 1000 gallons <br /> <br />Septic Tank Material: Concrete X Steel Other:. <br /> <br />Is Tank in Good Condition? Yes ~ No If No, please explain: <br /> <br />Are inlet & outlet fittings in place? Yes X No <br /> <br />Is disposal field backing into tank? Yes __ No 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 /> 6/2O/9'7 <br />DATE OF PUMPING <br /> <br />SIGN~TUR~ O~PUMP~P, <br /> <br /> <br />