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Counql <br /> M rt EXISTING SEPTIC SYSTEM DESCRIPTION <br /> OREGON <br /> Please answer the following questions as completely as possible, and to the best of your knowledge. <br /> 1. Your existing septic system consists of(check all that apply): <br /> Diti Septic Tank 0 Disposal Trenches ❑ Capping Fill [ f Sandfilter <br /> Vseepage Bed ❑ Cesspool or Pit 0 Unknown <br /> 0 Other (Describe) <br /> 2. When was your septic system installed? V-00 ce ? <br /> _.. -- - - - — - --- -P .)- -- .._._... - -- _._ .... ._..--- <br /> 3. Tank material: Concrete 0 Steel ❑Plastic or Fiberglass 0 Unknown <br /> 4. Septic tank volume(in gallons) 6a0 q I <br /> 5. When was the septic tank, last pumped? /?-I Attach receipt if available. <br /> 6. Number of disposal trenches E <br /> X P I R E <br /> 7. Total length of disposal trenches (in feet) <br /> 8. Do you propose to use the existing septic system? Yes El No❑ <br /> 9. Is your septic system currently in use? Yes El No❑ If no, date of last use <br /> 10. If the septic system currently serves a dwelling: - <br /> How many bedrooms are in the dwelling? ( How many people occupy the dwelling? Z-- <br /> 11. How many bedrooms will be in the proposed dwelling? 3 How many occupants? <br /> 12. If the septic system serves a business: <br /> How many total employees are there? <br /> Type of business <br /> 13. Is there a proposed change of use of your structure (home or business)? Yes 0 No-s-- <br /> If yes,please explain <br /> 14. Provide a plot plan(sketch)on the reverse side of this form showing the best estimated or actual <br /> measurements that locate the existing septic tank and disposal trenches,property lines, easements, <br /> existing structures, driveways, and water supply. Indicate the direction of north. If you are proposing to <br /> replace the septic system, indicate the test hole location. <br /> By my signature, I certify that the above information and the plot plan on the reverse side of this form are <br /> accurate and true to the best of my knowledge. <br /> (Date) Signature ofPi'perty Owner or Legally Authorized Representative <br /> Office use only: Record of existing system: Yes❑ No❑ Attached ❑ Datelssued <br /> Permit Number Certificate of Satisfactory Completion Issued: Yes❑ No❑ Initials <br /> Other file information_ <br />