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~ Marion County site ~ <br />/l~lli~/~/"'"' ORE¢O~' ON-S~ SEWAGE S~STEM <br /> SEPTIC TANK PU~PINGAND INSPECTION FORM <br /> <br /> TSe following requirements apply to the evaluation of an existing on-site <br /> sewage system. Please select the appropriate section and follow the directions <br /> carefully. <br /> <br />~f your sewage system is less than five {5) years old and a Certificate <br />of Satisfactory Completion has been issued for the system, the septic <br />tank does not require pumping at this time. <br />a. Authorization Notices do not require a field inspection of the <br /> system. A report can be issued based on a review of our files. <br />b. Existing System Evaluations d__o require a field inspection of the <br /> enti~e system and a report will be issued. <br /> <br />If your sewage system is more than five (5) years old and the septic <br />tank has not been pumped within the last five (5) years, follow the <br />directions below. If you have proof that the septic tank has been pumped <br />within the last five (5) years, section {a) will not be required. <br />a. The septic tank must be pumped by a D.E.Q. licensed septic tank <br /> pumper. <br />b. The septic tank pumper must complete the form below. <br />c. Authorization Notices and Existing System Evaluations require a <br /> field inspection to verify the location and condition of the <br /> septic system. <br /> <br />COMPANY <br /> <br />PROPERTY OWNER: <br /> <br />PROPERTY <br /> <br />*for septic pumper use only* <br /> <br /> D.~.Q. LiCeNSE #: <br /> <br />APPROXIMATE SIZE OF TANK: _gallons <br /> <br />SEPTIC TANK MATERIAL~ Concrete ; Steel ; other__ <br /> <br />IS TANK IN GOOD CONDITION? ............. Ye~__; NO__ <br /> <br /> If "No", explain: <br /> <br />ARE INLET & OUTLET FITTINGS IN PLACE? .. Yes__; NO <br /> <br />IS DISPOSAL FIELD BACKING INTO TANK? ... Yes ; No <br /> %f "Yes", explain: <br /> <br />DIAGRAM OF MOUSE AND SEPTIC TANK: (show detail with measurements) <br /> N <br /> <br />(503) 588-5147 Senator Building <br />F^x (503) 588~7948 ;~;~o High St. NE · Salem, OR 87301-367O <br /> <br />DATE OF PUMPING <br /> <br />SIGNATUP~ OF PUMPER <br /> <br />MC15-Sl9 <br />REV 1/93 <br /> <br /> <br />