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BUILDING INSPECTION <br />~150 LANCASTER DR NE - SUITE C <br />S^LEI"4 OR 97305 <br />PH# (50,~)588-5147 <br />FAX/~(S03)588-7948 <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 follow the directions carefully. <br /> <br />If your sewage system is less than five (5) years old and a Cert~cate 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, (A) will not be required. <br /> <br />A. The septic tank must be pumped by a DEQ licensed septic tank pumper. <br />B. The septic tank pumper must complete the form below. <br />C. A field inspection will be required by ow on-site staff to vedfy the location and condition of the septic system. <br /> <br />.... '- FOR SEPTIC PUMPER USE ONLY ..... <br /> <br /> Stayton, Mill City & Silverton Septic <br />Company Name: <br /> <br />PrepertyAddress: 9145 Bates Road Aumsville <br /> <br />Property Owner: Dave Gower <br /> <br />Septic Tank Material: Concrete × Steel <br /> <br />Is Tank in Good Condition? Yes X No <br /> <br />Are inlet & outlet fittings in place? . Yes <br /> <br />Is disposal field backing into tank? Yes __ <br /> <br />Services <br /> DEQLi~nse: <br />OR 97325 <br /> <br />37814 <br /> <br /> Size of Tank: !, 000 gallons <br /> Other:. <br /> <br />__ If No, please explain: <br /> No X Outlet baffle broi~e-Owner to ~epair <br /> <br /> NO X 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 />FIL <br /> <br /> q/ s/q <br />DATE OF PUMPING <br /> <br /> MC15-S19/REV 4-98 <br /> <br /> <br />