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12337718
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Last modified
8/26/2024 9:49:36 AM
Creation date
8/23/2024 3:08:27 PM
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Template:
Permits
Permit Address
14082 PIPER ST NE
Permit City
Aurora
Permit Number
555-24-006132-AUTH
Parcel Number
041W02DC02000
Permit Type
Authorization
Permit Doc Type
Permit Document
Status
Ready to Film
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• <br /> • <br /> • c <br /> Oregon Department of Environmental Quality <br /> • <br /> • Previous two years of maintenance records are available ['Yes ONo <br /> If you answered"No,"please explain below: <br /> • Previous two years of maintenance records are attached to this form DYes ❑No <br /> If you answered"No,"please explain below: <br /> • Additional Comments: <br /> 8. Please attach a copy of the following items to this form.Contact the DEQ,or the local Health <br /> Department to locate these items. - <br /> • • The septic system permit(s)to this form,if available <br /> • The as-built drawings)to this form,•if,available <br /> • The•Certificate bf Satisfactory Completion to this form,if available <br /> • Additional cairn:" <br /> • <br /> 9. Provide a'Site Plan <br /> • Please provide a sketch of the complete system(show only system components that were <br /> evaluated)on page 8 of this form,if a copy of the original,"as-built"drawing is not available. <br /> • Please provide a sketch of the complete system on page,8'of this form if the:briginal"as-built" <br /> drawing is not accurate or representative of the existingsYStem. <br /> • If the original"as-built"drawing is available for copy,and-the original appears to be accurate and <br /> representative of the existing system,write"see attached as-built"on page 8.of this form, <br /> redrawing the system is unnecessary. = - <br /> • Additional Comments: • <br /> • <br /> 10. Disclaimer: <br /> This evaluation report describes the septic system as it exists on the date of evaluation and to the <br /> extent that components and operation of the system are reasonably observable.DEQ recognizes <br /> that this evaluation report does not provide assurance or any warranty that the system will operate <br /> • properly in the future. <br /> 11. I hereby certify,by my signature,that the above information and the plot plan on the next page of <br /> this form are accurate and true to the best of my knowledge. <br /> 7fi sAct cd"--groo." 41:•••• <br /> Date Signa e of Qualified Septic System Evaluator <br /> Page 7 of 8 • <br />
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