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MARION COUNTY <br />BUILDING INSPECTION DIVISION <br />3150 LANCASTER DR NE - SUITE C <br />SALEM OREGON 97305-1398 <br /> <br /> ON-SITE SEWAGE SYSTEM <br />SEPTIC TANK PUMPING AND <br /> INSPECTION FORM <br /> <br />The following requirements apply to the evaluation of an existing on-site sewage system. Please select the appropriate <br />section and fullow 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 tire (5) <br />years, (A_)~wi~ll no~ ? 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: <br /> <br />Property Address: <br /> <br />Property Owner: <br /> <br />Septic Tank Matadal: <br /> <br />Stayton/Mill City & Silverton <br /> Septic Services DEQLicense: <br /> <br /> 8265 Anderson Road, Aumsville, Oregon <br /> Ivan & Mary Jo Thomas <br /> <br /> Concrete X Steel <br /> <br />Is Tank in Good Condition? Yes X No <br /> <br />Are inlet & outlet fittings in place? Yes X No <br /> <br />Is disposal field backing into tank? Yes __ No <br /> <br />34916 <br /> <br /> Size of Tank: <br /> <br /> Other: <br /> <br />__ If No, please explain: <br /> <br />1000 gallons <br /> <br />__. If Yes, 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 />DIAGRAM OF HOUSE AND SEPTIC TANK. SHOW DETAIL AND MEASUREMENTS: <br /> <br />N <br /> <br />6/10/97 <br /> <br />DATE OF PUMPING <br /> <br />MC15-S 18/REV 4-96 <br /> <br /> <br />