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r , . <br /> • <br /> flEc \7[ FL ( <br /> n. J <br /> Existing System Evaluation Report for Onsite <br /> 25 2021 <br /> Wastewater Systems BUILDING INSPECTION <br /> DEQ State of Oregon Department of Environmental Quality <br /> °i,, f°,°°a Onsite Program <br /> Ermrcammtal 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/deq/Residential/Pages/Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Doc ( ' -1/ J C-CS Telephone: 5-m3--93.3-5,1781 <br /> Site Address: /3, S 7"- City: 'A 77$ Zip Code:' -3y Z <br /> County: /1'a/'i'/J Lot Size: CP , to Square Feet(circle units) <br /> Legal Description: 3 Z/ 9e <br /> Age of wastewater treatment system / / (years) Is there a service contract for system components?/iit2 <br /> Date the septic tank was last pumped/n/z6/�m(please attach receipt if available) <br /> Number of people occupying dwelling e2 If unoccupied,for how long has it been vacant?/2cz r/- <br /> Was this section completed by the evaluator because owner or agent was unavailable? ,.5 <br /> The above information is true and to the best of my knowledge. <br /> //�72/�mg/ <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): ,p t /Spri <br /> Certification: <br /> NInstaller ElProfessional Engineer <br /> Maintenance Provider ❑ Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 37 22- <br /> Business name l71-01So.7 51"vi ex-, LL_C-. Email r-, el//--/op.SC / Go,i-( <br /> Business address /o g€0,AC s/ "//c./756 Cr, 9 3 6 7 Phonesm3�9 414/q <br /> Date of Evaluation: ®// V2—(p ) (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> rD/ <br /> Date( /DD/ Y) Signature of ualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />