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Marion County <br />· ' OREGON <br /> <br /> Date Eeo'd: <br /> <br /> site ~: <br /> ON-SITE SEWAGE SYSTEM <br />SEPTIC TILNK PU~ING AND INSPECTION FORM <br /> <br />The following requirements apply to the evaluation of an existing on-site <br />sewage system. Please select the appropriate section and follow the directions <br />oa~fully. <br /> <br />1. If 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 breed On a review of our files. <br /> b. E×isting System Evaluations d_~o require a field inspection of the <br /> entire system and a report will be issued. <br /> <br />2. 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 /> Authorization Notices and Existing System Evaluations require a <br /> field inspection rd verify the locatlon and condition of the <br /> septic system. <br /> <br /> *for septic pumper use only* <br /> <br />COMPAN~ NAME: ~ <br /> <br />PROPERTY OWNER: <br /> <br />D.E.Q. LICENSE <br /> <br />APPROXIM3~TE SIZE OF TANK: lO00 , gallons <br />SEPTIC TANK MATERIAL: Concrete~ ; Steel ; other <br /> <br />IS TANK IN GOOD CONDITION? ............. YeS ~ ; NO.__ <br /> <br /> If "No", explain: <br /> <br />ARE INLET & OUTLET FITTINGS IN PLACe? .. Yes _; No~l'-~''''lt3/;/~'';-~'':''~'/~' ~'~.~'""~'~/~-~) <br /> <br />IS DISPOSAL FIELD BACKING INTO TANK? ... Yes ..... ; No_~__ <br /> <br />If "Yes", explain: <br /> <br />DIAGRAM OF HOUSE AND SEPTIC TANK: <br /> <br />N <br /> <br />(show detail with measurements) <br /> <br />DATE OF ~UMPING <br /> <br />(503) 588-$147 Sen-~lor Building <br />~^~ (503) 588-7948 220 High $t. NE · Salem, OR 97301-3670 <br /> <br />PUMPER <br /> <br />MCI$-S]') <br />REV ]/93 <br /> <br /> <br />