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••• •-• •-• ••• •• ••• ,. . . . ' Oregon Department of Environmental Quality • : . . . . . „ . . . •:i Previous two years of maintenance records are avallable,, [ ]Yes ONo If yodansWered"NO"Please explain below . . : .. • .• . . . . . . .. •• • s' ! • • Previous two years of maintenance records are attached to this form OYes ONo!, If you answered"No"please explain below: . . . . .. • .. . .. . . . . . ;.: .:! Additional Coinments: ! • • - •• •• • • •• • • . . . 8 Please attach a copy of the following items to this form Contact the DEQ,or the local Health Department to locate these items. . . . ]:. • The septic system permit(s)to this form,if available • • . . • The as-built diawing(s)ito this form,if available • • The Certificate of Satisfactory Completion to this form,if available • Additional Comments:: • • . . . ... • ... . . „ . . • •• • • • • . . . 9 Provide a Site Plan !.; • Please provide a sketch of the complete system(show only system components that were evaluated)on pagel8 of this form,if a 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 no .p.ccigato•or representative of the existing Systeni. • If the ioriginali drawing is available for copy,and the original:appears to be accurate and !!: representative of the existing system,write"see attached as4iilt":on page 8 of this form, I • redrawing the System is unnecessary • • • • Additional Commentst"; • ; . . : • • • . • .. • .. . . ;; •• • • • :•• ••• ••• • 10. 1)iscbtimer: Tins evaluation report describes the septic system as it exists on the date of evaluation and to the • extent that components and 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.i • •• • 11. Thereby certify,by myjsignature;..;that the above information and the plot plan On thenext page of . . . , . . this form are, accurate and true to the best of my knowledge; . . . . . • • .2.-/ : .• Date • :" -; Signature of ified Septic System Evaluator• • • . . II :;: POge 7 of 8 !. • ..