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,OREGON <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 system is less tha~ five (5) ~ears old and a Certificate <br /> of Satisfactory Cemple=ion hag been issued for the system, the septic <br /> tank does not re,ire pumping at this <br /> a. Authoriza=ion No=ices ~.O no~ re, ire a field inspection of the <br /> system. A re~rt can be issued based on a review of our file~. <br /> b. Existing System Evaluations d~ re. ire a fie~d ins~ction of ~h~ <br /> entire ~yste~ ~d a ~e~rt will be issued. <br /> <br />2. If your sewage system is mo~e t~D five (5~ ~ear~ 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 fha: the septic tank has be~n pumped <br /> within t~e last five (5) years, ~ection (a) will not be re, ired. <br /> a. The septic tank must be pum~d by a D.E.Q. licensed septic tank <br /> pumper. <br /> b, The septic tank pum~r must complete the form below. <br /> Authorization Notices and ~xisting System Evaluatiou~ require a <br /> field ins~Ction to verify ~he location and condition of the <br /> septic system. <br /> <br />PROPERTY OWNER: ~ ~ <br /> <br /> - <br />A~ INLET & OUTLE~ FITTINGS IN PLAC~ .. Yes ; <br /> <br />IS DISPO$~ FIELD BACKING ~NT0 T~K~ ... Yes NO <br /> <br /> If "Yes", explain; <br /> <br /> OIAGRAR OF HOUSE AND S~PTIC TANK: <br /> <br />588'5147 Senator Building <br />~l ~R~-~4R 220 High St, NE, Salem, OR 97301-3670 <br /> <br />(show detail with measurements) <br /> <br />DATE OF PUMPING <br /> <br /> <br />