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<br /> Existing System Evaluation Report for Onsite
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<br /> ..: :-- ,: i:•!,--.114.•.0 :: •• • •:: •:;:ilkez-,%, Wastewater Systems : i i• • i:
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<br /> DEQ iii .'i :ii ::: ii -'i • i: . : :: :: .
<br /> State of Oregon Department of Environmental Qualityi
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<br /> Onsite Program .. • : : !: : ::: . - •:: : .•
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<br /> 165 East Seventh Ave,Suite:100.: .• • • i!! ... :.
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<br /> .• ,.:!psi*. :: ---:: : :.• :: Eugene, OR 9140i !: ;: s:. .. :! li ;: ;E i i ! :: ..•
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<br /> ;!Please answer thefolloWindquestiona complelely.Do not leave any Wank resOnses.*frite;;unknowO if
<br /> :: •: ii unknown;Refer tO'OregorcAdnilnistrative:ftule 340-071-01 5 for more information,and please visit
<br /> • -: ii li!titto://wvWv.oreoon.govideO/Residential/PaaesiSeoilc-Srnart aspic
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<br /> Septic SYSternOwner-rroviiled Information: : i . ii:ii : ! •• •.. .
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<br /> !!•Property Owner(sXSelleri): ,F(ia e) ii3g:;45-7(--- il ii Telephone:LLZ.C42. 4-8 dg
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<br /> •i . 4i li.s ite Addrss:/:79'.: e- ...0 f i r LA/ 5:•: ._ ;: •. i• :City:: 6e,..,/ :1 ! ziicodeV.7317•4 .•
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<br /> County . /74e/a:4 i! !.. Lot Size:i!eD;...,3 gc,L._s ]: Acres/Square Feet(circle units)
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<br /> Age of wastewater tree bi •>/...ent system /::7 ..ears) Is there a service contract f9r system components? /1•4::)
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<br /> Date Septic.tank was last pumped , 122(pleaae attach receipt if available)
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<br /> Number of people occupying dwelling 3 „?...:; ';• If unoccupied,for how long has it been vacant?:ects7` 7:cr', :
<br /> i.Was this secti9ri completed by the evaluator because owner or agent was unavailable?i yre_.. . :; •• .
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<br /> • .:, r.•The above information Is true and to the best of my jai. oWl edge. : ;; : : - •
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<br /> • •:! ::; ::it Datei(mtiODD/YstyY) i• ; .: 1 : ': Signature of Owner,or agent if present ! :
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<br /> .- .• ••• i;Name of person performing evaluation(please Print): !! g3,/,':
<br /> :. .•. i! • Certification: t! .:! , ;• .! :: :!! :• :: :: •: :.: ::: : :. :: •• .
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<br /> :.•. .; !:.E1 Installer•: i. :!! :i : :; :: :! 0 Professional Engineer
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<br /> •: ' :'. i;;g1 Maintenance Provider :- :I : :: 0 Environmental Health Specialist • •• .
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<br /> Ei .:liaiibeafAssopiation of Wastewater Technicians ., 0 Waste Water Specialist
<br /> : • i:: ii.0 :!Otlier.DEQ approved in writing(please describe)
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<br /> ertificatiOn NUrnber: :3 72-2. 57L.-:-. :: :.: i: ii i: ::
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<br /> :• :.. -; Business name'*_5.6;9 s4./ti,?/(ce.....i ii..- 1. iEmail i4‘2,S C-ff.P74:- C.;.,/.7 •
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<br /> -: .• iBusiness address :: 67',.gax . --"I M d r y57,o r,, 9 7-3 6 47:i: Phone...C.4U S1-7--(-/YV-6-
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<br /> •• :: ..Date of Evaluation:: /-2-/C!ar! ..2-,a)...2425 i; i :(1V1W3V/Yriry) ; ; :•
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<br /> .. :.: :'t hereby certify,by my'signature,thatl meet all the qualifications required to perform ansite:wastewater ! .
<br /> . ... • system evaluations in the state of Oregon pursuant to OAR 340-011-00$. : : :• ; -
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<br /> ' . • - : * ' :: •• Signature of Qualified Septic System Evaluator :
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<br /> Page 1 of 8 ! !; ! ; Updated 12/29/2016
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