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REcE,,En <br /> JA N 0 8 2021 Cr <br /> MARION COUNTY <br /> BUILDING INSPECTION <br /> Existing System Evaluation Report for Onsite 2i - � 2z2 <br /> Wastewater Systems <br /> State of Oregon Department of Environmental Quality <br /> Sate of Clegon <br /> Department ot Onsite Program <br /> Environmental 165 East Seventh Ave, Suite 100 <br /> Quality <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 <br /> visit:http://www.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: p� �,/ <br /> Property Owner(s)(Sellers): ix <br /> Property Telephone: 733 ' / / 2J <br /> Site Address: 2.52-?5'" 5A,JI/4M p ity: Z--0,o- Zip Code: <br /> County: 4,1 /l)A.I Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system (years) Ts 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 Owner,or agent if present <br /> Name of person performing evaluation(please print): <br /> Certification: <br /> TrInstaller ❑ Professional Engineer <br /> Maintenance Provider ❑ Envirotmiental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: XI 257 <br /> Jv <br /> r <br /> Business name Ac..7,,„.., x4,A) Email a-c sf.,/C{�r <br /> Business address e)9 q 0 K.A3//i4!,e IV 7 cc, Phone S-U VO/ <br /> Date of Evaluation: /O/Z/ 72 ) (MMIDD%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 340-07 155. <br /> Date(MM/DD/Y.'YY) Signature of Qua tfied Septic System Ev for <br /> Page 1 of 8 pdated 12/29/2010 <br />