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i y <br /> 1-1-bb.645?5 <br /> Existing System Evaluation Report for Onsite <br /> Wastewater Systems AUG 16 2024 <br /> DEQ <br /> State of Oregon Department of Environmental Quality <br /> Via,:; Onsite Program <br /> 165 East Seventh Ave, Suite 100 • <br /> Eugene, OR 97401 <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 visit <br /> http://www.oredon.dov/DEQ/WQ/bades/onsite/septicsmartaspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Amber Marie Johnson Hathaway Telephone: 503-510-0058 <br /> Site Address: 5133 Center St NE City: Salem Zip Code: 97317 <br /> County: Marion Lot Size: 5.73 ac Acres/Square Feet(circle units) <br /> Legal Description: 072W29AB01500 <br /> Age of wastewater treatment system (years) Is there a service contract for system components? No <br /> Date the septic tank was last pumped (please attach receipt if available) <br /> Number of people occupying dwelling 3 If unoccupied,for how long has it been vacant? <br /> Was this section completed by the evaluator because own or agent was unavailable? Yes <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): Tyler Fuhriman <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: EH-W-10199358 <br /> Business name Fuhriman Septic Design & ConsultirEmail tyler@fuhrimanconsulting.com <br /> Business address PO Box 19636 Portland, OR 97280 Phone 435-760-0717 <br /> Date of Evaluation: 8/12/2024 (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 OAR 340-071-0155. <br /> 8/12/2024 Ty Date <br /> -- <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />