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Oregon Department of Environmental Quality 1. General System Information The Existing System Evaluation Report form contains 8 pages. Some of the questions onthis form may not pertain to the system being evaluated,as there are many system.designs.If you(the. septic system evaluator)are unable to answer any of the questionson thisform please indicate,in writing,why this information was not available at the time the evaluation was completed. • Theexisting septic system consists of(check all that apply): tin Septic Tank ❑_ Cesspool 'r! Dosing Tank 1. Disposal Trenches/Leach Lines Multi-compartment Tank ❑ Capping Fill ❑ Seepage;Bed ❑ Sand Filter Note: Cesspools may be used only to serve existing sewage loads and if failing only be replaced with a seepage pit system on lots that are too small to accommodate a standard system or other alternative Onsite system. There is a permit for the septic system CiYes ❑No ❑Unknown • Permit Number(s) Cj s5 • Year original septic system installed:. / (YYYY) ONO record of installation date • Dates of subsequent repairs or alterations:tii4yhatal (YYYY) • All plumbing fixtures are connected to the septic system DYes RNo: r Unlmown If you answered"No"or`unknown,"please describe below: • Additional Comments: 2. Overall Septic.System Status • Discharge of sewage to the ground surface DYes , None.observed • Discharge of sewage to surface waters DYes 7.4No (None observed • Sewage backup into plumbing fixtures DYes JNo ❑Unknown • Additional Comments: 3. Septic tank In order to fully describe the condition of the tank,the septic tank may need to be pumped.Please indicate below if theseptic system tank,was pumped during the course of this evaluation. • Septic tank was pumped during thecourse of this.evaluation NYes ❑No: • If the septic tank was NOT pumped during the course of this evaluation,please explain(e.g. septic system owner declinedto have thetank pumped etc): Page 2 of 8