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(Supplemental Form) <br /> <br />In Or'er to properly evaluate wour existing sewage system, the following <br />information will be necessary: <br /> <br />Yf gout sewage system is less than five (5) gears old, and We <br />have an approved reco~d of :he system, we can proceed without <br />ang fur:her action on gout par:. <br /> <br />If gout sewage system is less than five (5) years old, and we <br />do not haw a r~cord of an approved installation of the sgstem: <br /> or; <br />~ yo~;r sewage sgstem is mere than five [5) gears old or has not <br />been p~ped within the last five gears: <br /> <br /> YOu must have the septic tank pumped. <br />b. H~ve =he Septic tank pumper complete the form below. <br />c. A field visit will be required by the Sanitarian =o <br /> v~r~fg the location and condition of the septic system. <br />d. If gou have proof that your septic =ank has been <br /> pumped wiuhln :bm lae~ fiv~ (5) gears, sections a & b <br /> will eot be required. <br /> <br />-For Septic Ta~ Pumper Use Only- <br /> <br />COMPANY <br /> <br />PROPERTY OWNER: <br /> <br />Stayton Septic Service <br /> <br />Bo~by & Bett.~y. Shepard <br /> <br />DEQ LICENSE NO: <br /> <br />34916 <br /> <br />ADDRESS WHERE TANK PUMPED: <br /> <br />91 61 Smith R~. SE <br /> <br />. Aumsvil~e, OR <br /> <br />APPROXIMATE SIZE OF SEPTIC TANK: 1000 <br /> <br />.gallons <br /> <br />Concrete <br /> <br />IS T~¥K IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR ELBOWS IN PLACE? <br /> <br />IS DR~INFIBLD BACKING UP INTO TAN~? <br /> <br /> XX YES; <br /> <br />.... XX YES; <br /> <br /> YES; <br /> <br /> NO <br /> <br /> NO <br />XX NO <br /> <br />If gee, explain;. <br /> <br />2/86 <br /> <br />DIAOP~t~! OF HOUSE AND <br />LOCATION OF <br /> <br />EX,~PLE: <br /> <br />Septic <br /> Tank <br /> <br /> <br />