Laserfiche WebLink
AUTHORIZATION NOTICE/EXISTING SYSTEM EVALUATION <br /> <br /> PUMPER FORM <br /> <br />In order to properly evaluate your existing sewage system, <br />information will be necessary: <br /> <br />the following <br /> <br />If your sewage system ks le~s than five (5) years old, and we have <br />an approved record of the system, we can proceed without any <br />further ~¢ti0n on your part. <br /> <br />If your sewage ~y~tem is less than five (5) year~ old, and we do <br />mot have a record of an approved installation of ~he ~yStem: <br /> <br />or; <br /> <br /> If your sewage system is more than five (5) year~ old Or has not <br /> been pumped within the last five years: <br /> <br /> You must have the septic tank pumped. <br /> ~ave the ~eptic tank pumper complete the form below. <br /> A field visit will be required by the Sanitarian to verify <br /> the location and condition of the Septic system. <br /> If you have proof that your ~eptic tank has been pumped <br /> within the last five (5) years, sections a & D will not be <br /> required. <br /> <br /> For ~epti¢ Tank ~, .~!~--r ~se Only <br />Stayton/Mill City & Silverton <br /> CO.ANY NAF~E: Septic Services DEQ LICENSE NO. 34916 <br /> <br />~BOP~RT~ Ot, rNSR: Arland Cook <br /> <br />ADDRESS ~VHERE TANK PUMPED: 8983 West Stayton Road~ SE <br /> Aumsville, OR 97325 <br /> <br />APPROXIMATE ~lZE OF SEPTIC TANK: 1000 .gallons <br /> <br />IS TANK ~N G~D CONDITION? X YEP; NO <br />~E BAFFLES OR ELBOWS ZN PLACEP X YES; NO <br /> <br />IS D~INFIELD BACKIN~ UP INTO TANK9 X <br /> At time of pumping, had surface water running back <br /> If ye~, explain; into tank. <br /> <br /> Concrete X Steel Other <br /> <br />SEPTIC TANK MATERIAL: <br /> <br />DZA~RAM OF HOUSE AND <br />LOCATION OF TANK: <br /> <br />example <br /> <br /> X <br />well <br /> <br />Rev 7/89 pb <br /> <br />N <br /> <br />SIGNATURE OF PUMPER: <br /> <br />DATE OF PUMPING: 12/26/90 <br /> <br /> <br />