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285 CHURCH ST NE <br />S^L£i,4 OR 97301 SEPTIC TANK PUMPING AND <br />~H# (503)5e~-S 147 R-~ <br />FAX~(SO~)Sae-794a ~g~ AP lgg8 ~ INSPECTION FORM <br /> <br /> BU LDING ~t~ite <br />The following requirementa app y to the avatuabon CT an <br />section and follow the directions carefully, <br /> <br />sewage system, Please select the appropr,ate <br /> <br />If your sewage system is less than five (5) years old and a Cer~ificme of Satisfactory Completion has been issued for <br />the system, the septic tank does not require pumping at tins 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 th.e septic tank has not been pumped w~tmn the last five (5) <br />years, follow the directions below. If you have proof that the septic ta~k has been pumped within me lasl 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 will be required by our on-site staff to verify the location and condition of the septic syslem <br /> <br />..... FOR SEPTIC PUMPER USE ONLY ..... <br /> <br />Company Name: <br /> <br />Property Address: <br /> <br />Property Owner: . <br /> <br />Septic Tank Material: <br /> <br />Is Tank in Good Condition? Yes <br /> <br />Are inlet & outlet fittings in place? <br /> <br />Is disposal field backing into tank? <br /> <br />Stayton Septic SeCTC~OBs OEQLicanse: 34916 <br />8057 Barbara Lane <br />Aumsville OR 97325 Size 0f Tank: 1,000 <br /> <br /> Other: not available <br /> <br /> __ If No, please explain: <br /> <br />Concrete__ Steel__ <br />X No <br />Yes X No <br /> <br /> Yes__ No <br /> <br />gaJlons <br /> <br />× 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 mspec~ed 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 /> <br />