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9 -c.5D.(3`1. IQ\ <br /> ,,-Q.ECIETV/En <br /> Existin System Evaluation Report for Onsit <br /> 9 Y AUG 18 L021 <br /> T=� eWastewater Systms <br /> eti MARION COUNTY <br /> DEQ State.of Oregon Department of Environmental Quality BUILDING INSPECTION <br /> : 9`92: 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 /> • .ttp1/www.orecton:caov/den/Residential/Paoes1Septic-Smart:aspx. <br /> Septic System.Owner-Provided Information: <br /> Property Owner(s)(Sellers): (4)0/ M/G/4 el P P, Telephone: Z ` 1G <br /> Site Address: .\ \ ( U) Ctx2C City: (1 F?A 5 Zip Code: 11 31462 <br /> County: V-31Psf-NI 0 C1 Lot Size: O a 9 Z. (110iinare Feet(circle units) <br /> :Legal;Description: 2.1 --Cc1S + Q( 1w 1 c)r k 9C)370 e Z(0 ) <br /> Age of wastewater treatment system?j)(years) Is there a service contract for system components? 1J <br /> Date the septic tank Was last pumped11\I1- , (please attach receipt if available) <br /> ::Number of people occupying dwelling 0 If unoccupied,for how long has it been vacant? k 2_02-0 <br /> Was this section completed by the evaluator because owner or agent was unavailable? <br /> The above® informa'on is true and to the best of my knowledge. <br /> l3/ ?-®.mil • <br /> Date(lvIlVI1DD/YYYY) Signature o Owner,or agent if present <br /> Name of person performing evaluation(please print): /eO✓ <br /> Certification.: <br /> ®. Installer. • ❑ Professional Engineer <br /> Maintenance Provider ❑ Environmental Health Specialist <br /> 0 W <br /> `.National Association of Wastewater Technicians 0 Waste Water Specialist <br /> • <br /> ;.Other:DEQ approved in writing(please describe) <br /> Certification Number: 3 <br /> Business name rffoil .5e'f VI ce:_S. LGC Email re✓.�Aid S � � <br /> Business:address PO iFtpc9C vt/ '"'/6-_,? ©` 977-3 Phone Sf"3.-g '�/9 <br /> cs- <br /> Date of Evaluation:: Cp7�/3/��-427.r/ r/ ( DD/YYYI) <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 /> Date .D Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />