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f <br /> cvegon bepartrneht of Environtoontat'Quiity <br /> 1. .General-SYstem InfortaitiOn <br /> The.EXiStitig Systern.EValtatiOnROPOOTORto::cofitaihs-81iAgo-:•sonie:4-the.questions on this <br /> form may not pertainto th0::$ystont.being evaluated,as there are many system designs If you(the <br /> septic system evaluator)are tinabi6..tnInsranypttho questions on tilia:foini140aaaHindir4t0,in <br /> writing,why this inforinationu4 not•availible.st the titoetheeValtiatinn*as completed. <br /> • The iatingiajJtic system cntiaiStstif(Chdeicill.that OplY): • <br /> r Septic.Tank 0 .ce,s4,001 <br /> O Dosing Tank Disposal Tr04010.-t44.0 Lines <br /> •O ..Multi-compartment Tank 0 Capping Pill <br /> :0 Seepage Bed 0 Sand:Filter <br /> Other . . . <br /> Note C?esspools may be used only to serge existing sewage loads and if failing only be replaced with <br /> Saee:pitsysteni..onlótthat etoosmáll tó.accomm.te:a.-standardsystem or other alternative. <br /> onsite.systetn. <br /> There is 4.perniit for the.septic system .DYes ONe :O.VjaktipWrt <br /> • Perritit:Ntiniber(s) ip,a144.4o44 . <br /> Year.sitici.01$etiiA-tysterti ,Eliio,t0-..oka.Of installation:date: <br /> • Dates:pfstibsequentrepairs: alteratiOns:, :CsirY)0 <br /> -Oro...60044g'.(46,t0$eptiqsAle:Oi..-OWS.. 0. ___JUriktioWn <br /> Ifyou pswerod1s1o"or'unknown,"please'describe below-.2 <br /> M.Ocd1#4.2.4.0.7. 41- 1/4i <br /> . . . . . . . . <br /> • lAaditi0114-0*1/1014S; <br /> . . .. . <br /> 2. :0,044*tilt sptenisotas:: <br /> Discharge-of.Sewagelto:theground surface Dyes-:0\l'o.. flone.cibserved <br /> • • <br /> • Disehatgenf:Se*age tO.Snrface*ato r--,rs 1.0.NO one ObSerVed <br /> • Sewage backup into plumbing fixtures ElYes o [alirdcriown. <br /> •• Aitional Coninieritat: -- • <br /> . . . . . . . . .. . . . „ . . . <br /> . . . . . " <br /> 3. Septic tank • <br /> In order to fully describe the condition the tank,the septic lank may needr.to.-be pumped.:Please <br /> indicate below if the septic system tank was:punipeddnting the courseof this eyaltiatinn, <br /> • $aptiC,..tiftik*.as pumped ciiiiiago*coOr$0,0f..this-041uAtiO4.Peo ONo <br /> • If the septic.:431*WP.$::$9,17.pumped during the course of this evaluation,please explain(e g <br /> septic:05.ton:owner declined to have.the tank pumped ete):. <br /> Page-2 of <br />