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Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality <br /> Onsite Program <br /> En"nment°' 1.65 East Seventh Ave,Suite 100 <br /> many <br /> Eugene, OR 97401, <br /> Please answer the following questions completely. Do not leave any blank responses.Write unknown if <br /> unknown. Refer to Oregon Administrative Rule 340-071-0155 for more information, and please <br /> visit:http:// moregon.govideq/Residential/PagestSeptio-Smartaspx. <br /> --- Septic System Owner-Provided information:- <br /> Property Owner(s)(Sellers): <br /> L L4.((a Telephone:7G0` i- I <br /> Site Address: 6 2,41 IA/ ,V City: be.: 5 Zip Code:97t�r'i' <br /> County: ,d'Aov\. <br /> . Lot.Size: I- 0.7 .quare Feet(circle units) <br /> Legal Description: -2.7 PC-60300 <br /> Age of wastewater treatment system 2-2-, (years) Is there a service contract,for system components? Ivin. <br /> A lease attach.recei t if`available) <br /> Date the septic tank was last pumped 7y,�� (p P <br /> Number of people occupying dwelling (LA/06y unoccupied,for how long,has it been vacant?140We bt1 tv1 <br /> ir <br /> Was this section completed by the evaluator because owner or agent was unavailable? Nf <br /> eS <br /> The above information is true and to the best of my knowledge. <br /> i- - - 3,0 <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Jeremiah Homutoff <br /> Certification: <br /> O Installer ❑ Professional Engineer <br /> Maintenance Provider 0 Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians 0 Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: l 2432 <br /> Business name Farmers Septic Company Email farmerssepticco@aol.com <br /> Business address 15.1.27 Evans Valley Rd NE,Silverton OR 97381 Phone 5034173-3344 <br /> Date of Evaluation: l 0- 3--Tr 2. (MM/DD <br /> I hereby certify,by my signature,that I.meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the.e state.of Oregon pursuant to OAR 340-071-0155 <br /> 0 b.s . •..ice .r .. -'.�/1...� L�3, <br /> V Date(MM/DD/YYYY) 'ignature of• .lifted Septic System • uator <br /> Page 1 of 8 Updated 12/29/2016 <br />