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BUILDING INSPECTION <br />285 CHURCH ST NE. <br />SALEM OR 97301 <br />PH~ (503)588-5147 <br />~'A~(50~)588-7948 <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 wi[[ be required by our on-site staff to vedfv 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 <br />Property Address: 7797 Albus Road, Aumsville, <br /> <br /> DEQ License: <br />Oregon <br /> <br />34916 <br /> <br />Property Owner: Robert Allen <br />Septic Tank Material: Concrete XX Steel <br /> <br />Is Tank in Good Condition? Yes XX No <br /> <br />Are inlet & outlet fittings in place? Yes XX No__ <br /> <br />Is disposal field backing into tank? Yes __ No XX <br /> <br /> Size of Tank: <br /> <br /> Other: <br /> <br />__ If No, please explain: <br /> <br />If Yes, explain: <br /> <br />500 gallons <br /> <br />Ii' 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 /> 8/08/9'7 <br />DATE OF PUMPING <br /> <br />MC } 5.S18,¢REV 4.96 <br /> <br /> <br />