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MARION 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 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 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: (.J~J~.~J ..<;~o,~e.~ 50;(_ ~o-ng¢~ue~'~,~ ~ DEQ License: <br /> <br />Prope~ Address: ~ ~ ~ <br />Prope~ Owner: ~e~ce ~ <br />SepticTank Material: Concrete /~ Steel <br /> <br />Is Tank in Good Condition? Yes <br /> <br />Are inlet & outlet fi~ngs in place? Yes <br />Is disposal field backing into tank? Yes ~ No /~fYes, explain: <br /> <br />If an effluent pump is included as paK of the septic system, ~e dosing ~nk and pump assembly must be inspected and <br />cleaned when the septic tank is pump~. <br /> <br /> Size of Tank: [ ~OO gallons <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 />F/I.E <br /> <br /> e,,/ /qs- <br />DATE OF PUMPING <br /> <br />S~NATURE OF ~ <br /> <br /> MCI 5-S18/REV 4-96 <br /> <br /> <br />