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Marion County <br /> OREGON <br /> <br />The following <br />sewage system. <br />carefully. <br /> <br /> ON-SITE SEWAGE SYSTEM <br />SEPTIC TANK PUMPING AND INSPECTION FORM <br /> <br />requirements apply to the evaluation of an existing on-site <br />Please select the aPProPriate section and follow the directions <br /> <br />If your sewage system is less than five (S) years old and a <br />Certificate Of Satisfactory completion has been issued for the <br />system, the septic tank does not require pumping at this time. A <br />field inspection will be made of the entire system and a repert <br />will be issued. <br /> <br />If your sewage system is more than five (5) years old and the <br />septic tank has not' bean'pumped within the last five (S} years, <br />follow the directions-below. If you have proof that the septic <br />tank has been pumped within the last five (S} years, sections (a} <br />and (b) will not be required.' <br />a. The septic tank must be pumped by a D.E.Q. licensed septic <br /> tank pumper. <br />b. The septic tank pumper must complete the form below. <br />c. A field inspection will be required by our on-site staff to <br /> verify the location and condition of the septic system. <br /> <br />COMPANY NAF~: <br /> <br />PROPERTY OWNER: <br />PROPERTY ADDRESS: //~'~J~ ~--~ <br /> <br />*for septic pumper use only* <br />(please print) <br /> <br />MC15-S19 <br /> 10-92 <br /> <br />A~PROXIMATE SIZE OF TANK: /~ gallons <br /> <br />SEPTIC TA~K MATERIAL: Concrete ; Steel :~; Other' <br />IS TANK IN GOOD CONDITION? ............. Yes ~ ; No <br /> If 'No", explain: <br /> <br /> IN PLACE? .. Yes ~ ; No <br />ARE <br /> INLET <br /> & <br /> OUTLET <br /> FITTINGS <br /> <br />IS DISPOSAL FIELD BACKING INTO TANK? ... Yes ~ No tx <br /> <br /> If "Yes', explain: <br /> <br />DIAGRAM OF HOUSE AND SEPTIC TANK:, (show detail with measurements) <br /> <br /> gRR.l~l~T Senator Building, 2nd Floor <br /> (503) <br /> 220 High SI. NE. Salem, OR 97301-3670 <br /> <br />DATE OF PUMPING <br /> <br />S tGN/~URE- OF PUMPER <br /> <br /> <br />