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• <br /> Oregon Department of Environmental Quality <br /> 1. General System Information <br /> The Existing System Evaluation Report form contains 8 pages.Some of the questions on this <br /> form may not pertain to the system being evaluated,as there are many system designs.If you(the <br /> septic system evaluator)are unable to answer any of the questions on this form please indicate,in <br /> writing,why this information was not available at the time the evaluation was completed. <br /> • The existing septic system consists of(check all that apply): <br /> MSeptic Tank [1Cesspool <br /> Dosing Tank IN Disposal Trenches/Leach Lines <br /> ❑ Multi-compartment Tank ❑ Capping Fill <br /> ❑ Seepage Bed ❑ Sand Filter <br /> ❑ Other <br /> Note: Cesspools may be used only to serve existing sewage loads and if failing only be replaced with <br /> a seepage pit system on lots that are too small to accommodate a standard system or other alternative <br /> onsite system. <br /> There is a permit for the septic system ❑Yes ❑No (]Unknown <br /> • Permit Number(s) <br /> • Year original septic system installed: (YYYY) ❑No record of installation date <br /> • Dates of subsequent repairs or alterations: "ZO/0 (YYYY) <br /> • All plumbing fixtures are connected to the septic system [Yes ❑No ?1Unknown <br /> If you answered"No"or"unknown,"please describe below: <br /> • Additional Comments: • <br /> il1_w /00O qAL cc�lr/c7,vv2 Iivsfsla6-�J' y_zL-Zoic <br /> CJ Few(Pr /c— 2:7_(.0 Z. <br /> 2. Overall Septic System Status <br /> • Discharge of sewage to the ground surface ❑Yes [No lone observed <br /> • Discharge of sewage to surface waters ❑Yes !No None observed <br /> • Sewage backup into plumbing fixtures ❑Yes RNo ❑Unknown <br /> • Additional Comments: <br /> 3. Septic tank <br /> In order to fully describe the condition of the tank,the septic tank may need to be pumped.Please <br /> indicate below if the septic system tank was pumped during the course of this evaluation. <br /> • Septic tank was pumped during the course of this evaluation ❑Yes ►AgNo <br /> • If the septic tank was NOT pumped during the course of this evaluation,please explain (e.g. <br /> septic system owner declined to have the tank pumped etc): <br /> Page 2 of 8 <br />