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· i ~UILDING INSPECTION <br /> ,__~j! . ,2SS, CHURCH ST NE SALEI'4 OR 97301 <br /> PH# (503)588-5147 <br /> FAXff(503) 588-7948 <br /> <br />RECEIVB <br /> <br />MARION COUNTY <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 ia 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 reid inspection will be made of the entire system <br />and a report will be issued. <br /> <br /> Stayton, Mill City & Silverton Septic Servi~)~License: <br />Company Name: <br /> 6654 Shaw Highw.ay SE Aumsvil.~e, OR 97325 <br /> Ernie Piluso Size of Tank: 1,000 gallons <br /> Concrete X Steel _ _ Other: <br /> <br /> __ If No, please explain; <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 /> follow/he directions below. If you have proof that the septic tank has been pumpe~5) <br />years' (A) will not be required,years, . //'-,.....~ ~_~,~/-'/ ' ~,~ <br />A. The septic tank must be pumped by a DEQ licensed septic tank pum.,gm'/,,.,.,.,.,.,.,.,.,~ <br />B. The septic tank pumper mu~t complete the form below. <br />C. Afield inspection will be required by our on-site staff to verify the Io~o~ti~;{ of~ theseptlc~s,=y~.//_, <br /> <br /> · - - ~ - - FOR SEPTIC PUMPER US5 ONLY .... <br /> ............. <br /> 37814 <br /> <br />No <br /> <br />Property Address: <br /> <br />Property Owner:. <br /> <br />Septic Tank Material: <br /> <br />Is Tank in Good Condition? Yes.. X No <br /> <br />Are inlet & outlet rittings in place? Yes.. X <br /> <br />Is disposal field backing into tank? Yes. <br /> <br />No X_.~__ 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 inspected and <br />cleaned when the septic tank is pumped. <br /> <br />DIAGRAM OF HOUSE AND SEPTIC TANK. SHOW DETAIL AND MEASUREMENTS: <br /> <br />S"I'G NATUR'~/~ ~OM~:]i~ <br /> <br /> MClS-Sl~REV 4-~ <br /> <br /> <br />