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t _ V • <br /> • <br /> Oregon Department of Environmental Quality <br /> 1. General System Information <br /> The Existing System Evaluation Report form contains 7 pages.Some of the questions on this <br /> form may not pertain to the system being inspected,as there are many system designs.If you(the <br /> septic system inspector)are unable to answer any of the questions on this form please indicate,in <br /> writing,why this information was not available at the time the inspection was completed. <br /> • The existing septic system consists of(check all that apply): <br /> ❑ Septic Tank ❑ Cesspool <br /> ❑ Disposal Trenches!Leach Lines ❑ Capping Fill <br /> ❑ Seepage Bed ❑ Sand Filter <br /> ❑ Other(please describe) <br /> Note:If the system is a seepage bed or cesspool contact your local County or DEQ office for further <br /> ' ' guidance. <br /> • • There is a permit for the septic system OYes ONo <br /> • Permit Number <br /> • • Date septic system installed: (YYYY) ONo record of installation date <br /> • All plumbing fixtures are connected to the septic system OYes ONo <br /> • <br /> If you answered"No,"please describe below: <br /> • Additional Comments: <br /> 2. Overall Septic System Status <br /> • Discharge of sewage to the ground surface OYes ONo <br /> • Discharge of sewage to surface waters DYes ONo <br /> • Sewage backup into plumbing natures OYes ONo <br /> • • Additional Comments: <br /> • <br /> • <br /> Site Address: • <br /> Page <br />