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Marion County <br /> OREOON <br /> <br /> site #; <br /> <br />SEPTIC TANK PUMPING AND INSPECTION FORM <br /> <br />The ~ollowing 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 you~ sewage system iS less.~han five ..[..~) year~ old and a Certificate <br /> ef Sa=isfactory Completion has been issued for the system, the septic <br /> tank does eot require pumping at this time. <br /> a. Authori~ation Notices ~p. not require a field inspection of the <br /> system. A repog~ can be issued ba~ed on a review of Our files. <br /> b. Existing Systeg~ Evaluations do require a field inspeotion of the <br /> entire System and a re~0rt will be issued. <br /> <br />2. ~f your sewage system is more ~han five (5) years old and the septic <br /> tank has not been pumped within the last five (5) years, fellew the <br /> directions below. If you have p=eef that the septic tank has been pumped <br /> wi~h&n the last five (~) yea~s, section (a) will not be required. <br /> ~he septic tank mus~ be pumped by a D,~.Q. licensed septic tank <br /> pumper. <br /> b. The septic tank ~umper ~ust complete the form below. <br /> A~:tbo~i~ation N~i~cs an~ ~istlng System 'E~a'luations ~eq~ire a <br /> field inspection to .~er%fy the location add condition Of the <br /> <br /> Stayton/Mill City & ~c~v~ pumper use only* <br /> <br /> COMPANY NAMe:.. Septic Services <br /> <br /> PROPERTY OWNER: B~ ~4at~ <br /> <br /> PROPERTY ADDRESS: ]0352~Leverm~n ~oad <br /> <br /> Aumsvi lle, OR 97325 <br /> <br /> APPROXIMATE -~I~ OF TANK: 1000 <br /> <br /> SEPTIC 9ANK MATERIAL: Concre~e_~(_; Steel ..... <br /> <br />Is TANK ~N GOOD CONDITION? ............. Yes__ 3( ; <br /> if "Ne", explain: <br /> <br />ARE INLET & OUTLET ~ITTINGS IN PLACe? .. Yes. X <br /> <br />IS DISPOSkL FIELD ~ACKING INTO TANK? ... Yes__; <br /> <br /> I~ "Yes", _e_~p_lain: <br /> <br />D.E.Q, LICENSE #: 34916 <br /> <br /> .... ~allons <br /> <br />et he~. .. . · <br /> No, ' [CE VED <br /> <br />OIAGRAM OF ROUSE AND $~PTIC TANK: (show detail with measurements} <br /> <br />, Iq~%1 ERR-'7q4~ 220 High SI, NE ~, ,%le,'n, OR 97301-3670 <br /> <br /> 7~30/94 <br />DAT~ OF PUMPING . <br /> <br /> MC15-Sl 9 <br /> <br /> <br />