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• <br /> 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 and pumping septic tanks as part of a Time of <br /> Sale Inspection or an Operation and Maintenance Permit. This inspection is to be completed by exposing septic tank lids <br /> and inspecting the 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: (t)S ��'f. lr yr F c-S City/TownshipNillage: a-Ivo �- <br /> Date Tank(s)Inspected/Pumped: //ei /zt <br /> Total Number of Septic Tanks: <br /> Septic Tank Sizes(in gallons :Tank#1 Tank#2 Tank#3 Tank#4 <br /> Tank Lid Types: ®Pre ..t concrete lid USteel plate <br /> URiser/w h secure lid at grade ®Other: <br /> Lid Condition: Lids intact an. 'n one piece? DYes UNo <br /> If No,specify wh h tank(s)and describe in det.' <br /> Tank Condition: Are there cracks with vi '.le gap. •n the interior of the tanks? ❑Yes ®No <br /> If Yes, specify which tank(s - d describe in detail: <br /> Outlet Device: Type of outlet dev. es: ❑Outlet'' ' ®Precast baffle UVented elbow <br /> Are the outlet •-vices intact%functional? ❑Yes UNo <br /> e'.G <br /> If No,spec' which tank(s)and describe i .etail: <br /> Check All That Apply: I. iquid level at or below the outlet—Tank# <br /> 111 Tank had runback from final disposal area—Tank <br /> ❑Tank is installed with an effluent filter—Tank# <br /> ®Tank used as pump chamber—Tank# <br /> Notes or RReecommendations: <br /> r vI,v' t_CA w aft:PV,ncACVNwA s,s/‘ <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: r'<c) <br /> Contractor's Signature: Date: g/lq Z`/ <br /> Rev.3.8.11 <br />