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BUILDING II~ISeECT10~I <br />985 CHURCH ST NE <br />SAL~Vi OR 97301 <br />PH# (50:~)588-5147 <br />FAX~(503)588-7748 <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) yearn 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 beea 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. <br />S. <br />C. <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 verify the location and condition of the septic system. <br /> <br />..... FOR SEPTIC PUMPER USE ONLY ..... <br /> <br />Company Name: Cl,'h/'~' ~'O~..~;~l/~"tb,'C DEQ License:~?~__~ <br /> <br />Property Owner:.. gallons <br />Septic Tank Material! Concrete ~ Steel <br />Is Tank in Good Condition? Yes .~/ No <br />Are inlet & outlet fittings in place? Yes ~ No <br />Is disposal field backing into.tank? Yes ~ No ~ If Yes, explain: <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 /> Size of Tank: <br /> <br /> Other. <br /> <br />if No, please explain: <br /> <br />DIAGRAM OF HOUSE AND SEPTIC TANK. SHOW DETAIL AND MEASUREMENTS: <br /> <br />N <br /> <br />SI~"N'ATU R ~"Q~ PUMPER <br /> <br /> <br />