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9ECEIVEDExisting System Evaluation Report for Onsit SEP 17 2019 <br /> Wastewater Systems MAFUON COUNTY <br /> Dot BUILDING INSPECTION <br /> State of Oregon Department of Environmental Quality <br /> savietowl <br /> 0,100,0,00 Onsite Program <br /> 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.orecton.ciovideoiResidential/Pages/Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(sXSelters): HALF A DOZEN ROSES LLC Telephone: <br /> Site Address:6148 Evans Valley Loop NE City. Silverton Zip Code:97381 <br /> County: Marion Lot Si• <br /> ze: 40.26 Acres/Square Feet(circle units) <br /> Legal Description: Acres 40.26 <br /> Age of wastewater treatment system ? (years) Is there a service contract for system components? no <br /> Date the septic tank was last pumped 8-14-19 (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? yes <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): Josh Hansen <br /> Certification: <br /> [✓ Installer ❑ Professional Engineer <br /> Q 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: 38968 , M271 <br /> Business name Oregon Sewer&Drain LLC Email josh@oregonsewer.com <br /> Business address PO Box 1282 Silverton, OR 97381 Phone 503-874-9414 <br /> Date of Evaluation: 8-14-19 (MM/DD/YYY1' <br /> I hereby certify,by my signature,that I meet all of the qualifications required to perf onsit 'utewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> 8-19-19 , <br /> Date(MM/DD/YYYY) Signal fQualitied tiep tic ~ stiro Evaluator <br /> Page 1 of 8 Updated 12i29/2016 <br />