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BUILDING INSP£CTION <br />285 CHURCH ST NE <br />SALEM OR 97301 <br />PH# (503)588-5147 <br />FAX~(503)588-79,1.8 <br /> <br />7 V ?- <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 win 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 <br />years, follow the directions below. If yo.u have proof that the septic tank has been pumped within the last five <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 cons. Dlete the form below. <br />A field inspection wilt be required by our on-site staff Io verify the location and condition of the septic syslem. <br /> <br /> ..... FOR SEPTIC PUMPER USE ONLY ..... <br /> <br /> Stayton, Mill City, & 8itverton <br />Company Name: ~oD~- i ,-, ~,~,.vi ,.,,,= DEQ License; #34916 <br /> <br />Property Address: 8814 W. Stayton Rd SE <br />Proper~Owner. Marsha Witt 1000 gallons <br /> <br />Septic Tank Material: Concrete X Steel <br />Is Tank in Good Condition? Yes X No <br /> <br />Are Inlet & outlet fittings in place? Yes X No <br />Is disposal field backing into tank? Yes No <br /> <br /> Aumsville, Or <br /> <br /> Size of Tank: <br /> <br /> Other: <br /> <br />If No, please explain; <br /> <br />X If Yes, explain; <br /> <br />If an effluent pump is included as par[ 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 /> ?-15-97 <br />DATE OF PUMPING <br /> <br />RECEIVED <br /> <br /> JUL 2 4 1997 <br />MARION COUNTY <br />BUILDING INSPECTION <br /> <br />Stayton Septic Service <br />SIGNATURE OFPUMPER <br /> <br />MCl$.SlS/REV 4-~* <br /> <br /> <br />