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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 appropfiata <br />section and follow the directions carefully. <br /> <br />1 <br /> <br />If your sewage system is less than I~ve (5) years old and a Certificate of Satisfactory ComplatJon 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 />--~. --The s~pti~ ~k must b~ pumped by a DEQ licensed septic tank pumper. <br />B. The septic tank pumper must complete the form below. <br />C. A f~eld inspection will be required by our on-site staff to vedfy,,the location and oondit~on of the septic system. <br /> <br />..... FOR SEPTIC PUMPER USE ONLY ..... <br /> <br />Property Owner: _'~Y~ Y'Y~<:~-~4 ~ <br />Septic Tank Material: Concrete ~,~ Steel <br /> <br />DEQ License: ~-~ ~ ~/~ , <br />Size of Tank: f ' gatlons <br /> <br />Other: <br /> <br />Is Tank in Good Condition? Yes ~ No If No, please explain: <br />Are inlet & outlet fittings in place? Yes ,~ No <br />Is disposal field backing into tank? Yes __ No ~ If Yes, explain: <br />If an effluent pump is included as pert 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 ANDMEASUREMENTS: <br /> <br />N <br /> <br />DATE OF PUMPING <br /> <br />SIGNATURE OF PUMPER <br /> <br /> <br />