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Checklist and Owner Statement for Hardship Renewals <br /> • <br /> Check all that apply: <br /> There are no unresolved pollution complaints concerning the septic <br /> system on the property where the hardship dwelling is located. Owner <br /> may not be aware if there is one, agent verifies. <br /> 1 The renewal was for the same occupants (both dwellings)who received the <br /> original authorization notice authorizing the hardship. <br /> (cis The applicant has presented evidence such as a receipt from a licensed <br /> sewage disposal service provider showing that the septic tank has been <br /> evaluated for solids content and pumped if needed within the last 10 years. <br /> • <br /> `iThe owner has kept current with required permits and inspections. <br /> The application for renewal has been made within 90 days of the current <br /> renewal date. <br /> • <br /> ❑ Sand filter, alternative treatment technologies,recirculating gravel filter <br /> and pressurized distribution system owners provided current maintenance <br /> records showing that the system has been properly operated and <br /> maintained. <br /> Applicant to take pictures of system area(tank/drainfield) and system <br /> pump components if present for submittal to DEQ. <br /> OWNER STATEMENT: <br /> To the best of my knowledge my septic system is functioning properly and I have not <br /> observed sewage surfacing on my property. I further certify that all plumbing <br /> fixtures (sinks, showers,toilets, etc) are connected to the existing septic system and <br /> that all setbacks between the existing system,wells, structures, driveways, etc. are <br /> still maintained and sufficient area exists so that a complete replacement area <br /> meeting all setbacks is available. <br /> c O. V iJ+ 1 404D <br /> Owner Name Date / <br /> Marion County Septic Procedures 2016 5 1 Page <br />