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Marion Count~l s~te <br /> OR E~O~N ON-SIdlE SEWAGE SYSTEM ~ ~ <br /> SEPTIC TAN~ PUMPING AND INSPECTION FOR~ ~] ~ <br /> <br />sewage system. Please select the appropriate section and follow the d~ons 1/11 <br /> <br /> · If your sewase system is less than five 5 ears old and a <br /> of Satisfactory Completion has been issued for the system, <br /> tank does not require pumping a~ this time ~'%~h'~4...,,,~. <br /> a. Authorization Notices do not require a field inspection of <br /> System. A report can be issued based on a review of OUr fi~es. <br /> b. E~isting System Evaluations d__o require a field inspecnion Of the <br /> entire system and a report will be issued. <br /> <br />COMPANY NAME= <br /> <br />PROPERTY <br /> <br />PROPERTY ADDP~SS= <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 (~) 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 t~nk pumper must co~p!ote 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 /> *for septic pumper use only* <br />Stayton/Mill City & Si~ver~0n <br /> SeD~C Service~ D.E.Q. LICENSE $: 34916 <br /> <br /> Jerry Job_risen <br /> <br /> 210 Patton Read <br /> <br /> ",',·- Detroit, Oregon, 97342 <br /> <br />APPROXIMATE SIZE OF TANK: 500 ~gallons <br /> <br />S~PTIC TANK MATERIAL: Concrete ; Steel X ; Other <br />IS TANK IN GOOD CONDITION? ............. Yes X ; No <br /> If "No", explain: <br /> <br />ARE INLET & OUTLET FITTINGS IN PLACE? .. Yes }( ; NO <br /> <br />IS D~$POSAL FIELD ~ACKING INTO TkNR? <br /> <br />DIAGRAM OF MOUSE AND SEPTIC TANK: <br /> <br />(show detail with measurements) <br /> <br />($03) S88-5147 Senator Buiidin8 <br />~,.,x (503) 588-7948 220 Hish $~, NE · Salem, OR 97301-3670 <br /> <br />4/26/95 <br /> <br />DATE OF PUMPING <br /> <br /> ~F~U~PER/ <br /> <br /> ~CIP-S]9 <br /> REV 1/93 <br /> <br /> <br />