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i <br /> 1V Er <br /> MARION <br /> o nNic INSPECTION SEPTIC TA / ' U, PI a . <br /> 5155 Silverton Rd NE AND INSPECTI •� C "'. j <br /> -�-- Salem OR 97305 n, 1 RIGA <br /> Fax Phone:(503j 588 7948 47Dori!,.Dj JG INs r <br /> • <br /> 0, <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)years,follow the <br /> directions below. If you have proof that the septic tank has been pumped within the last five(5)years, (A)will not be required. <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 and provide a receipt to the customer. • <br /> C. A field inspection may be required by our onsite staff to verify the location and condition of the septic system. <br /> FOR SEPTIC PUMPER USE ONLY <br /> Company Name: ACE P j 9 C SQ It V i Ca. DEQ License: 3 3 o13 <br /> Property Address: (,S 0 c Lci. 1Q.S4‘d4 Or. NE. SCi(eurk • <br /> Property Owner. Fa ti ;okno VA L A L Vi 4 fi r. Size of Tank: 100 0 gallons <br /> System Currently Serves: Residence: yeS #of Bedrooms: 4Q Occupied? Yes X No <br /> Commercial: #of Employees/Seating: Occupied? Yes - . No <br /> Septic Tank Material: Concrete: X Steel: Other: <br /> Is Tank in Good Condition? Yes X No If No, Explain: <br /> Was Visit to Site for Inspection of Septic Tank Only? Yes X No <br /> Are Inlet&Outlet Fittings In Place? Yes X No / Solids level in tank? Normal: X Excessive: • <br /> Was Tank Pumped? Yes X 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 inspected and <br /> cleaned when the septic tank is pumped. Y <br /> Dosing Tank? Yes X No / Serviced? Yes X No Date 5-2 5 - 1 b <br /> Sand Filter System? Yes No X / Serviced? Yes No X Date <br /> ' TS( E-DRAW DIAGRAM OF HOUSE AND SEPTIC <br /> bo TANK.SHOW DETAIL&MEASUREMENTS. <br /> ✓ � � L N <br /> r 7 <br /> -i . , <br /> ul „...,, i , <br /> i .. <br /> • <br /> 1 9• t t p , - S <br /> ..,, 4rk g AA I±t I` , -k y <br /> • cel: c--P Z Gt ' C. o <br /> �Op1 iC • <br /> �_{ Q tJ-1 <br /> DATE OF PUMPING/INSPECTION <br /> iIt [ 1 71.-ot cl.) ,' 7-7&f/6Z___ .a,e4.- --,--- <br /> SIGNATURE OF PUMPER <br /> _.__. ii <br /> ( <br /> MC:S-19;rev 8/00:1/01;9/01;6/03;6/04,1/06 Page 1 of 1 . <br />