Laserfiche WebLink
. , . <br /> (.7 0--)<Ct- • <br /> Existing- System-Evaluation Report for Onsite <br /> Wastewater Systems <br /> • <br /> DEQ State of Oregon Department of Environmental Quality <br /> f Oregan <br /> °wa fted& Onsite Program oe�runeirta 9 • <br /> 165East Seventh•Ave, Suite 100 • <br /> asetilty <br /> Eugene;•.OR`974.01 • <br /> Please answerthefollowing'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://www.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> • <br /> Septic System Owner-Provided Information: <br /> • Property Owner(s)(Seellerrs): - Telephone: <br /> • Site Address: 129 � City: bk ? \ Zip Code: <br /> County: ►�(\ Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: ' <br /> • Age of wastewater treatment system2A(years) Is there a service contract for system components? <br /> Date the septic tank was last pumped (please attach receipt if available) <br /> :Number of people occupying dwelling If unoccupied,for how long has it been vacant? • <br /> • Was this section completed by the evaluator because owner or agent was unavailable? <br /> The above information is true and to the best of my knowledge. • <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print):_ Richard Westerlund—NAWT 12493ITC • <br /> Certification: <br /> ❑ Installer . ❑ Professional Engineer • <br /> • <br /> ❑ Maintenance Provider ❑ Environmental Health Specialist <br /> • ❑✓ 'National Association of Wastewater Technicians ❑ Waste Water Specialist_ <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 33013 • • • <br /> Business name Ace Septic and Excavating Email office@ace-septic.com <br /> Business address PO Box 9177, Brooks, OR 97305 • Phone 503-393-1033 <br /> Date.of Evaluation: 0 b! 0? ? (MM/DD/YYYY) . <br /> I hereby certify,by my signature,that I meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the'state of Oregon pursuant to OAR -071-01 . <br /> OGfc2= Z . /2 . <br /> I � <br /> Date(MM/DD/YYYY)• • . Signature of Qualified Septic System Evaluator <br /> • <br /> • • Page 1 of 8 Updated 12/29/2016 • <br />