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BUILDING INSPECTION <br />285 CHURCH ST NE <br />SALEM OR 97301 <br />PH# ($03)588-5 147 <br />FAX#(503)SB8-7948 <br /> <br /> ON-SITE SEWAGE SYSTEM <br />SEPTIC TANK PUMPING AND <br /> INSPECTION FORM <br /> <br />The following requirements apply to the evalumion of an existrng on-site sewage 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 Cemficate of Satisfactory Completion has been ~ssued for <br />the system, the septic tank does not require pumping at this time A field inspection wilt 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, iA) will not be required <br /> <br />A~ <br /> <br />The septic tank must be pumped~-~ DE-Q li~ense-d ~eptic tar~-k pure--per. <br />The septic tank pumper must complete the form beiow. <br />A field inspection will be required by our on-site staff to verify the location and condition of the septic System. <br /> <br /> ..... FOR SEPTIC PUMPER USE ONLY ..... <br /> cJ.:, ........................ si ,,e ton"-' ' -' ' ' <br />Company Name: Septic Services <br /> <br />Proper~Address: ~03.t3 ,~l~,C~k Koad~ SE <br />Property Owner: Nick C. Shible¥ <br />Septic Tank Material'. Concrete ~- Steel, <br /> <br />is Tankin Good Condition? Yes X No, <br />Are inlet & outlet fittings in place? Yes ~ No <br />Is disposal field backing into tank? Yes ~, No X If Yes, explain: ,, . <br />If an effluent pump is included as part of the septic system, the dosing tank and pump assembly must be inspectec~ and <br />cleaned when the septic tank is pumped. <br /> <br /> DEQ License: 34916 <br /> <br /> Aumsv~.lle, ,Or, e~f9n ,,, <br /> Size of Tank; 1. 0 O0 ....gailons <br /> Other: <br /> <br />if NO, please explain: <br /> <br />DIAGRAM OF HOUSE AND SEPTIC TANK, SHOW_DETAIL AND MEASUREMENTS: <br /> <br /> Hay ,28, 1996 <br /> DATE OF PUMPING <br /> <br />"SIGNCURE OF'PU~PER / <br /> <br /> <br />