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ON NOTICE <br /> ~.¢SupplementaI Form) <br /> <br /> =valuate your exi~tin'g ~ewage system, the following <br /> <br /> _~ur sewage system is less than ~ive (5) gears old, and we <br /> · ~a~ an approved recof~ of the s~stam, we can proceed without <br />any further action on ~our part. <br /> <br /> If your s~wage system is less than five (5~ yaar$ o1~, and we <br /> ~o not have a r~ord of an approved installation of th~ s~stem: <br /> <br /> If your sewage system is more than five (5) years old or has not <br /> been pu~ped within the last five wears: <br /> <br /> a. You must have the septfc tank pumped. <br /> Nave the ~eptic t~n~k pumper complete the fo~ below, <br /> A field visit will be required by the Sanitarian ~o <br /> verify the location and Gondition of the Septic system. <br /> d. Zf you have proof that your septic tank has been <br /> pumped within the last five (5) years, sections a & b <br /> will not be ~equired. <br /> <br />COMPANY NAME: <br /> <br />PROPERTY OWNER: <br /> <br /> '-Fo~ Septi~ Tank ~u~= Use on~- <br />Stayton Septic Service <br /> <br />Delmer Lambrecht <br /> <br />DE~ LICENSE NO: <br /> <br />34916 <br /> <br />ADDRESS WHERE TANK PUMPED: . <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: <br />IS TANK IN GOOD CONDITION? <br /> <br />5336 ~uderson Rd. <br /> <br />Aumsville, <br /> 1000 <br /> <br />Ore~on <br /> <br />~allons concrete <br /> <br /> YES; NO <br /> <br />ARE BAFFLES OR ELBOWS IN PLACE? <br /> <br />X~ YES; NO <br /> <br />IS DRAINFZELD BACKING UP INTO TANK? <br /> <br />YES; ~X NO <br /> <br />If ~e$, explain; <br /> <br />DIAGR~3~ OF HOUSE AND <br />LOCATION OF <br /> <br />EXAMPLE: <br /> <br />6'~ Septic Tank <br />1~£2 ~ Vor~h <br /> <br />Rev. 2/86 <br /> <br /> <br />