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~/tlar,on Counl/y ON-S~TE S~-WAG~ SYSTEM <br />~', ' ()R~'G'ON ' SEPTIC TANK PDI~PINO AND INSPECTION FO~ <br /> <br /> ........ The following requiremengs apply eo ~he evaluation of an existing on-sita <br /> sewag~ system. Please select the appropriate section and fellow the directions <br /> <:a~efully. <br /> <br />If your sewage system is less than fiv~ (5) yea~s old and a <br />Certificate of Satisfactory Completion has been issued for the <br />system, the septic tank does act ~equire pumping at this time. A <br />field inspection will be made of the entire system and a report <br />will be issued. <br /> <br />If your sewage system is more than five (5) years old and the <br />septic tank has not been pumped within the last five (5) years, <br />follow the directions below. If you have proof that the septic <br />tank has been pumped within the last five (5) years, sections (a) <br />and (b) will not be required, <br />a. The septic tank must be pumped by a D.E.Q. licensed septic <br /> tank pumper. <br />b. The septic tank pumper must complete the form below. <br /> A field inspection will be required by our on-site staff to <br /> verify the location and condition of the septic system. <br /> <br />*for septic pumper use only* <br />(please print) <br /> <br /> t <br /> <br />PROPERTY ADDRESS' / /5...~ %~ 7~T/gLA~ ~ <br /> o ,? cC> <br />APPROXIMATE SIZE OF TANK: /~OO <br /> <br />~EPTIC TANK MATERIAL: Concrete,~; steel_ __ <br /> <br />is TANK IN GOOD CONDITION? ............. Yes__ <br /> <br /> gallons <br />; Other <br /> <br /> ; NO <br /> <br /> If "No", explain: <br /> <br />ARE INLET & OUTLET FITTINGS IN PLACE? .. Yes <br /> <br />iS DISPOSAL FIELD BACKING INTO TANK? ... Yes__; No__ <br /> <br /> If "Yes", explain: <br /> <br />.~O~AGRAM OP MOUSE AND SEPTIC TANK; (show de,ail with measurements) <br /> <br />T <br />N <br /> <br /> 50' <br /> <br /> .... ~ ~-~ <br />m, '1 5-S19 <br /> ,,;v 10--92 <br /> <br />(503) 588-5147 Sen,~tor Building, 2nd Floor <br /> 220 High St. NE ' Salem, (')R 97'1(11. thTII <br /> <br /> MAR 2 i 1995 <br />iV{AB{ON COUNTY c~ <br />BUILDING INSPECTION <br /> <br />DATE OF PUMPING <br /> <br /> <br />