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SEPTIC SERVICES • <br /> 503-949-2772 503-580-4012 <br /> Septic Tank Inspection/Pumping Report <br /> This form is to be used by Licensed Septage Haulers who are Inspecting andpumping.se tic tanks as part of a Time of <br /> Y A 3 P � <br /> Sale Inspection or an`Operation and Maintenance Permit. This inspection is to be completed by exposing septic tank lids <br /> and inspecting the <br /> interior of the septic tank The inspection scope is limited to those details that can be observed by <br /> opening an access to the septic tank Specifically, completing this form does NOT require exposing the entire top of a <br /> septic tank When inspecting buried masonry products contractors are urged to use.caution. - <br /> Address I'LCD' akgzev,;City/Cownshipl liage: ° % <br /> Date Tank(s)Inspected/Pumped /l(7/2 i <br /> Total Number of Septic Tanks <br /> Septic Tank Sizes(in gallons) Tank#1 (Oa) Tank#2 Tank#3 Tank#4 <br /> Tank Lid Types. °Precast concrete lid Lteet plate <br /> ORiserlwith secure lid at grade ❑Other. ' <br /> Lid Condition: Lids;intact and in one piece? __titles U No <br /> If No,specify which tank(s)and describe in detail <br /> Tank Condition: there cracks with visible gaps on the interior of the tanks? Yes 0 No <br /> If Yes, •ecify which tank(s)and describe in detail: <br /> Outlet Device Type of outlet devices: II Outlet"T" recast baffle °Vented elbow <br /> Are the outlet devices intact/fun '.nal? 21 Yes ❑No <br /> If No,specify which tank(s)and desc •e:in detail: <br /> Check All That Apply: D Liquid level at or belo. I e outlet-Tank <br /> Wank had runba rom final disposal area-Tank.# <br /> OTank:is inst. •d with an effluent filter—Tank# <br /> UTank u--• as pump chamber—Tank# <br /> Notes or Recommendations: <br /> I inspected and pumped the tanks at the above address and hereby attest that the conditions as described in this report <br /> reflect actual site observations. I understand that the County may require corrective action as the result of this report,and <br /> that any corrective action must be approved by Washtenaw County. <br /> Company Name: W <br /> Contractor's Signature: Date: 1 j 6 2— <br /> !! �. Rev.3.841 <br />