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BUILDING INSPECTION <br /> ON-SITE SEWAGE SYSTEM <br />.............. 1 TANK PUMPING AND <br />PH~ (50~)588-514~ ~ ~ ' ~ <br />F~(50~)588-7948' INSPECTION FORM <br /> <br />The following requirements apply to the evalua, tlon of an existing omsite 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 wilt 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 />Stayton, Mill City & Silverton Septic Services <br />Company Name: DEQ License: 3 7 8 14 <br /> <br />PropertyAddress: 10664 James Way Drive <br />Property Owner: John Hermsdorf <br /> <br />Septic Tank Material: Concrete X Steel <br /> <br />Is Tank in Good Condition? Yes X No <br /> <br />Are inlet & outlet fittings in place? Yes X No . <br /> <br />Is disposal field backing into tank? Yes __ No__ <br /> <br /> SE Aumsville OR 97325 <br /> <br /> Size of Tank: 1,000 <br /> <br /> Other: <br /> <br />__ If No, please explain: <br /> <br />X If Yes, explain: <br /> <br />gallons <br /> <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 />DIAGRAM OF HOUSE AND SEPTIC TANK. SHOW DETAIL AND MEASUREMENTS: <br /> <br />N <br /> <br />DATE OF PUMPING <br /> <br />SIGNATURE Or PUMPER <br /> <br />MCIS-Sla/REV 4-96 <br /> <br /> <br />