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MAR{ON COUNTY <br />BUILDING INSPECTION DIVISION <br />3150 LANCASTER DR NE - SUITE C <br />SALEM OREGON 97305-1398 <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 nspect on w I 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 />A. <br />B. <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 tieid 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:d~"[~',~ ~ t~ ~-"~'- __~ ~.~ DEQ..Lij;ense:~"'~ <br /> <br />Septic Tank Material: Concrete ~ Steel Other:. <br />Is Tank in Good Condition? Yes/~L No If No, please explain: <br />Are inlet & outlet tittings in place? Yes/%~'" No <br />Is disposal field backing into tank? Yes __ -No ~ Yes, explain: <br /> <br />If an effluent pump is included as part of the septic system, the dosing tank and ~Dump assembly must be inspected and <br />cleaned when the Septic tank is pumped. <br /> <br />DIAGRAM OF HOUSE AND SEPTIC TANK. SHOW DETAIL AND MEASUREMJSNTS: , <br /> <br /> · <br /> <br /> -9/qlem .._ <br />DATE OF PUMPING <br /> <br />31GNATURE ~PEI~ - <br /> <br /> <br />