10512294 - Laserfiche WebLink

Home Browse Search

. .. 1111 i 1 ;1111 11 Ti 11 IQregon Department of Environinerital Quality • Previous two years of maintenance recordsare available DYes DNo If you;answered"No,"please;explain below: • • • Previous two years of maintenance records are attached to this form DYes ONo If you answered"No,"please explain below: • Additional Comments:::: • 8 Please attachia copy of the following items to this form Contact the DEQ,or the local Health Department to locate these items. zz • The septic system permit(s)to this form,if available • The as-built drawings)to this form,if available • The Certificate of Satisfactory Completion to this form,if available • Additional Comments: • 9. Provide a Site Plan ii! • Please provide a sketch of the complete system(show only system components that were evaluated)on page;8 of this form,if acopy of the original"as-built"drawing is not available. • Please provide a sketch of the complete system on page 8 of this form if the original"as-built" drawing is not accurate or representative of the existing system. • If the original;"as built"drawing is available for copy,and the original appears to be accurate and representativeof the existing system :write"see attached as-built"on page 8 of this form, redrawing the system is unnecessary. Additional Comments:: • • • 10. Disclaimer: 1 1111 11 1.1111 1 This evaluation report:describes the septic system as it exists on the date of evaluation and to the extent that co npor ents and operation of the system are reasonably observable.DEQ recognizes that this evaluation report does not provide assurance or any warranty that the system will operate properly in the future 1 11 11. Thereby certify,by my.signature that:the above information and the plot plan on the next page of this form are accurate and true tothe best of my knowledge. :: • 8 Date Signature of Qualified Septic System Evaluator Page7of8