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Oregon Department of Environmental Quality <br /> • Previous two years of maintenance records are available ❑Yes ❑No <br /> If you answered"No,"please explain below: <br /> • Previous two years of maintenance records are attached to this form ['Yes 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 drawing(s)to this form,if available <br /> • The Certificate of Satisfactory Completion to this form,if available <br /> • Additional Comments: <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 original"as-built" <br /> drawing is not accurate or representative of the existing system. <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 /> 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 /> 4-16-24 <br /> Date Signatur o ie Septic System Evaluator <br /> Page 7 of 8 <br />