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285 CHURCH ST NE <br />SALEM OR 97301 <br />PH# (503)588-5147 <br />FAX~(503)588-7948 <br /> <br /> APR 1 2 1996 <br /> <br /> ON-SITE SEWAGE SYSTEM <br />SEPTIC TANK PUMPING AND <br /> INSPECTION FORM <br /> <br />The following requirements apply to the evaluati~l~l~l~~T-~9~lsewage system. Please select the appropriate <br />section and follow the directions carefully. <br /> <br />If your sewage system is less than five (5) years old and a Certificate of Satisfactory Completion has been issued for <br />the system, the septic tank does not require pumping at this time. A field inspection will be made of the entire system <br />and a report will be issued. <br /> <br />If your sewage system is more than five (5) years old and the septic tank has not been pumped within the last five (5) <br />years, follow the directions below. If you have proof that the septic tank has been pumped within the last five (5) <br />years, (^) will not be required. <br /> <br />The septic tank must be pumped by a DEQ licensed septic tank pumper. <br />The septic tank pumper must complete the form below. <br />A field inspection will be required by our on-site staff to vedfy the location and condition of the septic system. <br /> <br />..... FOR SEPTIC PUMPER USE ONLY ..... <br /> <br />Company Name: .,,//~,'~/~" _~; ~c"" ~'"~/'~' ~'~-.,~., Z~.. <br />Prope~ Address~.~~ /(~/~/~ ~ <br />Prope~ Owner: ~~ ~ (~ ~ <br />Septic Tank Material: Concrete Steel <br />Is Tank in Good Condition? Yes ~ No <br />Are inlet & outlet fiEings in place? Yes ~ No <br />Is disposal field backing into tank? Yes ~ No ~ If Yes, explain: <br /> <br />DEQ License: ,_~ ~(:~) I ~-~ <br /> <br />Size of Tank: ,/,/~)(~)d..~ gallons <br /> <br /> Other: <br />~ If No, please explain: <br /> <br />If an effluent pump is included as part of the septic system, the dosing tank and pump assembly must be inspected and <br />cleaned when the septic tank is pumped. <br /> <br />D!AGPJ),.M OF HOUSE AND SEPTIC TANK. SHOW DETAIL AND MEASUREMENTS: <br /> <br />N <br /> <br />DATE OF PUMPING <br /> <br />SI(~NA-"FI~RE-~F PUMPER <br /> <br />MC 15-S 18/REV 4-96 <br /> <br /> <br />