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Marion County <br /> O£EGON <br /> <br /> ON-SITE SEWAGE SYSTEN <br />SEPTIC TANK PUJ~INGAHD INSPECTION FORM <br /> <br />Site <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 />If your sewage system is less than five (5) years old and a Certificate <br />of Satisfactory Completion has been issued for the system, the septic <br />tank does not require pumping at this time. <br />a. Authorization Notioes do not require a field inspection of the <br /> system. A report can be issued based on a review of our files. <br />b. Existing System Evaluations do require a field inspection of the <br /> entire system and a report will be issued. <br /> <br />If your sewage system is more than five 15~ years old and the septic <br />tank has not been pumped within the last five (5) years, follow the <br />direotions 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 tank pumper must complete the form below. <br />c. Authorization Notices and Existi~g SY_s~em _~yaluati0ns~requi~~ a <br /> - -~ieid in~ect~on t~ verify the location and condition of the- <br /> septic system. <br /> <br />COMPANY NAME: <br /> <br />PROPERTY OWNER: <br /> <br />PROPERTY ADDRESS: <br /> <br />APPROXIMATE SIZE OF TANK: IOOd) <br />SEPTIC TANK MATERIAL: Concrete ; Steel X ; <br /> <br />*for septic pumper use only* <br /> <br /> .gallons <br />Other <br /> <br />IS TANK IN GOOD CONDITION? ............. Yes X ; <br /> If "No", explain: <br /> <br />ARE INLET & OUTLET FITTINGS IN PLACE? .. Yes X ; No <br /> <br />IS DISPOSAL FIELD BACKING INTO TANK? ... Yes ; No <br /> <br />If "Yes", explain: <br /> <br />DIAGRAM OF HOUSE AND SEPTIC TANK: (show detail with measurements) <br /> <br />N <br /> <br />SIGNATURE OF PUMPER <br /> <br />(503) 588-5147 Senator Buildin$ <br />~AX (~03) 588-7948 220 Hish St. NE · Salem, OR 97~01-3670 MC15-S19 <br /> ~ 1/93 <br /> <br /> <br />