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, .. .. • • • :. ::::. : I • • • .:. .. 1:.,, :: :': ... ::i E:: •:• .!: . : ::: •: i: :: : ::i: . ••• • -•• - • • .:.', :: ::: .. :. :i ..: :". :i: i.. :.: : .: :.: .: :: :: •: ::':: ' • - : ,... . .. :: . :;, : .„:,, ., -..; ,: . -,, •.. ;E .• : '; :; :: ;: :. :: ;!:*: •• •• ••• . i:-. Oregon Department of EOirornental Quality :: „:' ' ,: •• : I':: :• . : • .• • . •,:i .- i:: •: . ..: • : • :.• •.. .• • • :: :: "" :: • .. . : :: • • • - . - •• . - _ ... . . .. . :::: :.: .••• .• . . • : . .. • • - -• •• - • • -- •• • ••• • • •: :. : • • - . . . . 4,-: Previous two years of Maintenance records are available!. Erires DNo . .. .. :, • . .. E If you answered"No,"please explain below: :: : ::::. • . ..• - : ..• -: :: .E.:: : . . ..- . : , . •.. . . . • • •••-. ..... . : . . . ... .. . . .. • - • . ... . . . . :.** " • • ••• .; „ .. :: - •. : . : • -.• --• • • • • - ..„ , ,„ „. „;, . .. . . •. • • : •.: : . . • • •. . ...: . .• - • -.. .. .. .. .... . • .. . _ . ... . . . •••• 0• Previous two years of maintenance records are attached to this form OYes EiNo:i • •. . .:- • ..: ::. • ::. If you ansWered"No,"please explain below: . .. . . -• •• •- • ••• • : : : . .: . :.• • •• - •.. .. .. . . , .:. : .::•. •• • •.• . . :. :. . .. . .. . . . . .. . •• Additional:Comments: ; . - E! .: !! • r! !::!! ! : . :: : : . •. .. . . .• : .• . . ... • . . . . . . . .. .. .• .. .... ... ... ... ... . „:::! : : : . . . . .• .: .. .. . .. • • -. . .. . ... .. . . . .. .. .. . . : ::: .E, ,•:. ::: E:E :: Ei: E:. :E: ::: •E :. :.• E: E: :. :: iii ! : . . . : • .. • • • . . . .• . .•: :: .. ::: ::. ... ::: : . •. : .. .. :E: E : • • • . . --, •::. •!! :::E •••• ::! •! ::. ::: :: *:. : :: .i :: :: -... : 1.; ! ' : • : : • . . a: Please attach a copy of the following items to this form;Contact the DEQ, or the local Health . • .. : • Department to these items... . . .. : a. The septic system Permit(s)to this form,if available :: -i•E;-: • • . . :.: :. i: :E:E: •.,: •: •:•: :: ':-•: •: The as-built drawing(s)!to this form,if available : :' !!!:: E! i • • . -• EE::: . !.: • !: E-.: i The Certificate of Satisfactory Completion to this form,if available . : :!: 1:: li „:•:: a! Additional Coroments..•:!. !! :!! ;: !: „:. • ii;i! . . .• • .. :: • - : ::: .: ::. -•: .:. ::• :.• :E • :. .• :: • :. :E : ; • .. . . . .. .. . :. ;:, , :,,.• „:. :, :• .„• .•: ::. :• : :. ; .; :: :: :• E, E • .. . . .; ., -:- .: .: Er :. .E ::: :* :: • - ' : -. - : '-' • '. •: . .• h •: . • :- ... .. i .. E: • •:: :• : . ..• .: .• .. . . . . 9. Provide a!Site Plan • •. . • :: : :::•:: - •• Please provide a sketch of the complete system(show only system components:that*ere . E evaluated)on Page 8 of this form.if a.copy of the original"as-built"drawing is not available, ! • :• !: , .• : • Please providea sketch of the complete system on page 8 of this form if the oriiinal!"as4built" .. .. :.• : : ,!:. '. drawing is not accurate or representative of the existing system • • : •; i! : . • If theoriginal"as-builf.'drawing is available for copy,and the.original appears to be accurate and . ! • representative of the existing system,write"see attached as;rfrUilt":on page 8 of this form, • ! " : •:. „: 1 :;•; • ;1: redrawing the system is unnecessary !;! :: i; . „.„ EE . ; ; . • • •,• ..• ::. .:: •: :: .: EE EEE E: • . . : • • Additional COrnments:: ;: :: *E; •i ;; . !: !!!;! • : ••.. •. • •- . . .. . .. ...• ... . • • ••.. . . .. . . . .. . .... . • .. • . •. ... .. . .. .. .. ... . . . .. .. . " - " " •" " - " •• • • • • - ... .. ... . . . .. ... . .. .. . . . :. : . . .• . „ . . . . •„: .: :;! ;:i • :: !:! •-: ::- :• ;!E •!. r• ;• •:: • :: . • !:::' . : . - • • •. . . . . ... . . • • . .. ... . .. ... . : .:• .:. :E: :EE E.. •EE . E:. . .• •• : . . .: E: : •: •: :: • . :- •. - :: -:E :: !: :: ::::: •. - .. - • . 10. Disclabier: ;! !.! . ;* : ': ;; ::: ;::;r; . •. ... ... . . . . EEE EE . •.. • • This evalnation report describes the septic system as it exists on the date of evaluation and to the • :: :.: :: :: : :.. • - -- •• • .:: ::E ..;: ;.: extent that components and operation of the system are reasonably observable DEQ recognizes . .. .. . ... . . . .. . . .E. ::* ::E: •:: that this evaluation,report does not provide assurance or any warranty that the system will operate properly in the funne.;.i :, .; :ii :! •i :' i! i; : ; . .. . .. . . .. .. . . .. . .. ... .. . .. .. .. .. ... .. . . . . .. :. :. . .. . . .. .. .. . ... ... .. . . . .. . . .. .. .. ... ... .. ... . .. ... .. . . .. .. . .. .. : : •: • • . • : . Il. I hereby CertifY,by my signature,that the above information and the plot plan on the.next page of .• ::: :• •:-:: "• •• -• . " • •! ::: ;; „„::: E;:. this forniare accurate and true to the'best of my Imowledge!„! .. - •.. . . •: -- .• ... - - • • : .../±_i_66;- .. . .: • , • - . •. • :!! !..E! !!:. !: :: -:i 4?-. itt3og!! .:P•419 : :: ; . .; .: :: , • • :: r• . . .• •- - - • • • :-. ::: :.! ;:•E! :: Da e ••• E!! i! ": :!, ' ! i;: • i Signature.of u ified Septic System Evaluator .. ... . . - :::. E•:: :'.:: !•.• r: :: :E :.. ::: •: E: ;- : • . ;EE;E . . • -.. .. ... .... . . . .. . .. . . •. . . ... .. .. .. .. .. ... .. .. .. .. . . .. - : . . •. . . : :E. EEE ... : ... :: E:: :: : :: •.: : . - ‘; .. .i ii • • , . • •. • • • . •.: :1.: ::::.:. ::: ;: ;.• ;!: :1: ',: i'. . :: . Page 7 of 8 .•- .: . .. . „. .•: . : : .:i . • • • • - •• • E:i"E- -• • • - • - . --- . . . •• • - • - • -:- - - - . • . Ei::1 E . .:: •-.: E•E •E: . :E: i] ::: i!E •: :E. :'• . •:: ' :. :E :: :: i:E i: : : .:i • • ..! ';'. EEE !:: • E:: :i :E: *E: .: E': ::: :' :' :* ' • • ' . .. .