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23-0014yyZ 4vrH <br /> RECE - VED <br /> M Via' 25 2921 <br /> _""-=� Existing System Evaluation Report for Onsite <br /> - . MARION COUNTY <br /> r r:- , Wastewater Systems <br /> __ y E3UILDING INSPECTION <br /> DEQ State of Oregon Department of Environmental Quality <br /> s otore9o�,: Onsite Program <br /> o�peie,�,rot 9 <br /> m^^ ' 165 East Seventh Ave, Suite 100 <br /> Eugene, OR 97401 <br /> Please answer the following 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 visit <br /> http://www.oregon.gov/deg/Residential/Pages/Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: <br /> f <br /> Property Owner(s)(Sellers): Me ` <br /> jv . f r ffrek Telephone: 5. — 3 02 -1'3 <br /> Site Address: 2_,2,0 g 'f uY L k City: Zip Code: 57 3575 <br /> County: I/tM"1tn., Lot Size: ; 0 I Acres Square Feet(circle units) <br /> Legal Description: 1 _. F - rl 6e, <br /> Age of wastewater treatment s-ystem (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 0 ,or a ent if present <br /> , Name of person performing evaluation(please print): yj7f <br /> Certification: • <br /> Installeri§... <br /> ❑ Professional Engineer <br /> Maintenance Provider El Environmental Health Specialist <br /> National Association of Wastewater Technicians g-, Waste Water Specialist <br /> ❑ Other:DEQ approved in writin (plea e describe) <br /> Certification Numbe • <br /> n <br /> Business name a f* �7 maill 6 c1 GC S01,AT 11/94A e7iL.e ww- <br /> 2aqn <br /> Business address 2-7 i ' , �04- ��rn hoOne- 39?%ll�j 36 Z- 2,3‘0,0 <br /> Date of Evaluation: /2 _ e7W5 (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications requ' d to perf r nsi, •. • • ater <br /> system evalu lions in he state of Oregon pursuant to OAR 340-071-01 . <br /> Dat (MM/D /YYYY) Signature of Qualified Sep • Sys,em Evaluator <br /> Page 'I of 8 Updated 12/29/2016 <br />