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MCountY arion <br /> EXISTING SEPTIC SYSTEM DESCRIPTION <br /> OREGON • <br /> Please answer the following questions as completely as possible, and to the best of your knowledge. <br /> 1. Your existing septic system consists of(check all that apply): <br /> DSeptic Tank 1N Disposal Trenches • 0 Capping Fill 0 Sandfilter <br /> Seepage Bed ❑ Cesspool or Pit ❑ Unknown <br /> ❑ Other (Describe) • <br /> 2. When was your septic system installed? <br /> _._ _...-----•---- - - -- - —- - � e� - -�ermitNumber).__._._ .... ._..--- <br /> 3. Tank material: Concrete 0 Steel ❑Plastic or Fiberglass ❑ Unknown <br /> 4. Septic tank volume(in gallons) • /06 4/e)(Di <br /> 5. When was the septic tank, last pumped? 12/21/Z0 Attach receipt if available. <br /> 6. Number of disposal trenches <br /> 7. Total length of disposal trenches (in feet) <br /> 8. Do you propose to use the existing septic system? Yes 0 No, <br /> 9. Is your septic system currently in use? Yes 0 No, If no, date of last use ' <br /> 10. If the septic system currently serves a dwelling: - <br /> How many bedrooms are in the dwelling? How many people occupy the dwelling? <br /> 1,3a� k444114 <br /> 11. How many bedrooms will be in the proposed dwelling? How many occupants? <br /> 12. If the septic system serves a business: <br /> How many total employees are there? <br /> Type of business <br /> 13. Is there a proposed change of use of your structure (home or business)? Yes ❑ No <br /> If yes,please explain <br /> 14. Provide a plot plan(sketch) on the reverse side of this form showing the best estimated or actual <br /> measurements that locate the existing septic tank and disposal trenches,property lines, easements,existing - <br /> structures, driveways, and water supply. Indicate the direction of north. Ifyou are proposing to <br /> Y P P g <br /> replace the septic system,indicate the test hole location. <br /> By my signature, I certify that the aboue inf ation and the plot plan on the reverse side of this form are <br /> accurate and true to the best of le . <br /> VA/=- _ <br /> (Date) Signature ofProperty ed Representative <br /> Office use only: Record of existing system: Yes❑ No❑ Attached 0 Date Issued <br /> Permit Number Certificate of Satisfactory Completion Issued: Yes D No0 Initials <br /> Other file information: <br />