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(Supplemental Form) <br /> <br />In'order to properly evaluate your existing sewage system, the following <br />information will be necessarg: <br /> <br />rf your sewage system is less than five (5)'years old, and we <br />have an approved reco~d Of =he system, we can proceed without <br />any further action on your part. <br /> <br />2. If gout sewage SgStem is le$~s than five (5) years old, and we <br /> do not have a record of an approved installation of the s~stem: <br /> or; <br /> If your sewage sgstem is more than five (5)Hears old or has not <br /> been pumped within the last five years: <br /> <br /> a. You must have the septic tank pumped. <br /> b. Have ~he septic tank pumper complete the form below. <br /> e. A field visit will be required bg the Sanitarian to <br /> verifg the location and condition of the septic system. <br /> d. If ~ou have proof that your septic tank has been <br /> pumped within the last five (5) years, sections a & b <br /> will not be required. <br /> <br /> hFor Septic Tank Pumper Use Onl~- <br /> <br />COMPANY NA~IE: <br /> <br />,,, Stay,on Sept%._e.,,S, ervice <br /> <br />DEQ .LICENSE NO: <br /> <br />34916 <br /> <br />PROPERTY OWNER: <br /> <br />~.J. Chapweske <br /> <br />ADDRESS WHERE TANX PUMPED: <br /> <br />,,9684 Silver Falls Hwy. <br /> <br />Aumsville, OR <br /> <br />APPROXIMATE SIZE OF SEPTIC TANX: <br /> <br />1000 <br /> ~allons <br /> <br />concrete <br /> <br />IS TANK IN GOOD CONDITION? <br /> <br />ARE BAFFLES OR ELBOWS IN PLACE? <br /> <br />IS DRAINFIELD BACKING UP INTO TANK? <br /> <br />~YES; .... NO <br />XX YEs; NO <br /> <br />YES; ~ NO <br /> <br />If yes, explain; ........... <br /> <br />DIACRA~! OF HOUSE AND <br />LOCATION OF <br /> <br />EX..~P LE : <br /> <br />6'~ Septic Tank <br /> <br /> <br />