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t ~l.~, a~gon Count~ s~t~ #, <br />"~ $~P~IC ~ANK~UMPIN~AND INSPBD'~ON FORI~I <br /> <br /> The following requirements apply to the evaluation of an existing on-site <br /> sewage system. Please select the appropriate section and follow.the directions <br /> carefully. <br /> <br /> 1. If your sewage systeta i~ ~ess than f%,we (5) years o~d and a Certificate <br /> of Satisfactory Completion has been issued for the system, the septic <br /> tank does no% re~ire pumping at thi~ t~me. <br /> a. Authorization Notices do not re~ire a field inspection of the <br /> <br /> b. Existing System ~va~uat~ons ~ re,ire a field inspection of the <br /> entire sy~te~ and a report w[~ be issued- <br /> <br /> 2. If your sewage system is more than,five,,, {5) years old and the septic <br /> tank has not been pumped withi~ the last-five (5) years, follow the <br /> d~rections below. If you have proof that the septic tank has been pumped <br /> within the last five (5) years, section (a) will not be r~ired. <br /> a- The septic tank mu~= be pumped by a D.E.Q. licensed septic tank <br /> pumper. <br /> b. The septic tank ~umper must complete the form below. <br /> c. Authorization Notices and Existing System Zvaluations require a <br /> field inspection to verify the location and coadition of the <br /> septic system. <br /> <br /> *for septic pumper uss only* <br /> <br /> '' <br /> <br />APPROXI~TE SIZ~ OF ~ANK: .gallons <br />SEPTIC TANK ~TERIAL: Concrete _,, ; Steel~ ; Other <br />IS TANK IN GOOD CONDITION? ............. ~es~ ; NO <br /> If "No", explain: <br /> <br />ARE INLET ~ OUTLET FITTINGS:IN PLACE?., Ya$~,~ No / <br /> <br />IS DISPOSAL FIELD BACKING INTO TANK? .., Yes <br /> <br />If "Yes", explain= <br /> <br />DIAGRAM OF HOUSE /~ID SEPTIC TANK: <br /> N <br /> <br />(show detail with measurements) <br /> <br />556-5'~ 47 Sena[or Building <br /> qRR-7QZ/R 220 Hi~:h St. NE.Salem, OR 97301-3670 <br /> <br />MCI..--.>~ <br /> <br /> <br />