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• , <br /> Oregon Department ofEnvironments!Quality <br /> t. G'eneral,Syste-in,Information <br /> The Existing System Evaluakti Report form contains&pages:Some of the questions on this <br /> Corte 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 tithe the evaluation was completed. <br /> Tile existing septic system consists of"(check all that apptY): <br /> tV Septic Tank 0 Cesspool <br /> L Dosing Tank 0 Disposal Trenches/Leach Lines. <br /> 0 Multi-compartment Tank 0: Capping Fill <br /> Seepage Bed Ej Sand Filter <br /> 0 Other <br /> Note Cesspools may be used only to serve existing sewag.eloads and iffailing only be replaced with <br /> a seepage pit system on lots that are too to accommodate a standard system or other alternative <br /> • Onsite system. <br /> There is apemtit for the septic system rofQYes ONo OUnknown <br /> Permit Number(s) e3-stod <br /> 1(13 <br /> e Year original septic system installed: '1 (YYYY) 0No record of installation date <br /> Dates of subsequent repairs or alterations: 7 1-'7-4175 (yyyy) <br /> a Aq plumbing&mires are connected to the septic vstent ['Yes 0No ilintalown <br /> If you answered"No"or"unknown,"please describe below: <br /> * Additional Contments: <br /> Ttok 7-t7-Y <br /> a Overall-Septic System Status. <br /> Discharge.of sewage to the ground surface ales rkm, --`1\lone observed <br /> Discharge of sewage to surface waters DYes yjNo LI None observed <br /> a Sewage backup,into plumbing fixtures 0Yes MNo Dinknown <br /> Additional Comments: <br /> 3. Septic tani <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 [Yes NNo <br /> Ifthe 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 /> Pa9a 2 of 8 <br />