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Existing System Evaluation Report for Onsite oZ1A-6b5v1� <br /> Wastewater SystemsDEQ <br /> C� M <br /> State of Oregon Department of Environmental Quality JUL 16 2024 <br /> . Onsite Program _ <br /> �, - -- <br /> 165 East Seventh Ave, Suite 100 MARION COUNTY <br /> Eugene, OR 97401 BUILDING INSPECTION <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: <br /> Property Owner(s)(Sellers): Telephone: <br /> Site Address:22431 River Rd NE City: St Paul Zip Code:97137 <br /> County: Marion Lot Size: 71.05 Acres/Square Feet(circle units) <br /> Legal Description: 042W040000900 <br /> Age of wastewater treatment system 1999 (years) Is 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?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): Richard Westerlund--NAWT 12493ITC <br /> Certification: <br /> ❑ Installer ❑ Professional Engineer <br /> ❑ 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: 33013 <br /> Business name Ace Septic and Excavating Email office@ace-septic.com <br /> Business address PO Box 9177, Brooks, OR 97305 Phone 503-393-1033 <br /> Date of Evaluation: ®y I lei/zo^[._ (MM/DD/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 0 3 -071-0155. <br /> P 0 .7' ! g <br /> Date(MM/DD YY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />