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,.~ BUll. DING INSPECTION <br /> 285 CHURCH ST NE <br /> SALEM OR 973Ot <br /> <br />ON-SITE SEWAGE SYSTEM <br />SEPTIC TANK PUMPING AND <br /> <br /> o,,~. PH# (503)$88-S 147 <br /> F,~XtI(503)S88.7948 t%A IO COUaT' INSPECTION FORM <br /> ~UtLO~NG iNSPECTION <br /> <br />The following requirements apply to the evalu~Uon of an exisUng on-site sewage system. Please select the appropriate <br />flctior~ and follow the directions carefully. <br /> <br />., <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 close not require pumping at this time. A field inspecUon will be made of the entire system <br />and a roper[ will be Issued. <br /> <br />If your sewage system is more than five (5) years old and [he septic tank has not been pumped wiLl, in the last five (5) <br />years, fallow Ihe direcUons below, If you have proof that the septic tank has been pumped within the last tire 15) <br />years, (Al 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 />~;t a y t, otl., Mill <br />ompany Name: <br /> <br />Property Address:, <br /> <br />Propert~ Owner: <br /> <br />Septic Tank Material: <br /> <br /> ..... FOR SEPTIC PUMPER USE ONLY ..... <br /> <br />City and $tlverton Septic Services <br /> OEO License'. 37814 <br /> <br /> [55 Detr, 0tt Avenue Detroit OR 97342 <br /> <br /> Fraqcie Johnso.n Size of Tank: , 750 gallons <br /> <br /> Concrete, Steal x Other: <br /> <br />Is Tank In Good Condition? Yes..,, X, No If No, please explain: <br /> <br />Are Inlet & outlet tiltings In piece? Yes X No <br /> <br />Is disposal field backing into tank? Yes__ No X If Yes, explain: <br /> <br />If an effluent pump la included as part of the septic system, the dosing tank and pump assembly must be inspected and <br />cleaned when the sapUc tank is pumped. <br /> <br />DIAGRAM OF HOUSE,AND SEPTIC TANK. SHOW DETAIL AND MEASUREMENTS: <br /> <br />N <br /> <br />Pumped by Wayne per our records <br /> <br />SIGNATURE OF PUMPER <br /> <br /> <br />