Laserfiche WebLink
Oregon Department.of Environmental Quality <br /> 1 General System Information <br /> The Existing System Evaluation Report form contains 8 pages::Some of the:questions on,this <br /> form may not pertain to the system being evaluated,as there are many system designs.If you(the <br /> septic system evaluator)are unable to answer any of the.questions on this form please indicate,in <br /> ..: writing,why this information was not available at the time the evaluation was completed: <br /> The existingsepticof system consists check all that apply): <br /> e p Y ( PP Y): <br /> Septic Tank ❑ . Cesspool <br /> ICI Dosing Tank tiZ Disposal Trenches/Leach Lines <br /> Multi-compartment Tank ❑ Capping Fill <br /> Seepage Bed. ❑ " Sand Filter <br /> El Other <br /> Note: Cesspools may be used only to serve existing sewage loads and if failing only be replaced with <br /> a seepage:pit system on lots that are too small to accommodate a standard system or other alternative <br /> onsite system: <br /> There is apermit for the septic system ®;Yes: ❑No DUnknown <br /> •. Permit Number(s) /®`0,‘ <br /> • Year original septic:system installed: 1 9 08 (YYYY) ❑No record of installation date <br /> • Dates of subsequent repairs or alterations: /kit,- (YYYY) <br /> •: All plumbing fixtures are connected to the septic system ❑Yes lNo (—Unknown <br /> If you answered"No"or"unknown,"please describe below:.: <br /> 17612.5e/009M fly y <br /> i €1- i . 2.4692127 <br /> • Additional Comments: <br /> 2. Overall Septic Systeui;Status <br /> • Discharge of sewage to the ground surface DYes If No (None observed <br /> • Discharge,of sewage to surface waters:. ['Yes No ❑None observed <br /> • Sewage backup into plumbing fixtures DYes gNo ❑Unknown <br /> • Additional Comments: <br /> 3: Septic tank <br /> In order to fully describe the condition of the tank,the septic tank may need to be pumped.Please <br /> indicate below if the septic'system tank was pumped during the course of this evaluation. <br /> • Septic tank was pumped during the course of this evaluation DYes EdNo <br /> • If the septic tank was NOT pumped during the course of this evaluation,please explain(e.g. <br /> septic system owner declined to have the tank pumped etc): <br /> Page 2 of 8 <br />