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EXISTING SYSTEM EVALUATION REPORT EXISTING SEPTIC TANK EVALU • its 0E11 <br /> Existing System Evaluation Report for Onsite JAN <br /> 25 <br /> 1019ry, . _- <br /> DEQ Wastewater Systems ��1� �N CoU�v ? <br /> State of Oregon Department of Environmental Quality ( cj-. PECTI <br /> �� <br /> Onsite Program L� <br /> 165 East 7th Avenue,Suite 100 <br /> Eugene,Oregon 97401 <br /> Please answer the following questions completely. Do not leave any blank responses.Write unknown it <br /> unknown.Refer to Oregon Administrative Rule 340-071-0155 for more information,and please visit <br /> http://www.oregon.gov/DEQ/WQ/pages/onsite/septicsmartaspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers) ANGIE FENCL Telephone <br /> Site Address 11247 GROVE ST Sf, City: MEHEMA Zip Code: 97384 <br /> County: MARION Lot Size: 0.54 ACRES Acres/Square Feet(circle units) <br /> • <br /> • '��� i, Legal Description: T 09 R 2E SEC 1868 TL 1600 <br /> . <br /> Age of wastewater treatment system N/A (years) Is there a service contract for system components? NO <br /> Date the septic tank was last pumped UNKNOWN (please attach receipt if available) <br /> Number of people occupying the dwelling N/A If unoccupied,how long has it been vacant N/A <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 /> 11/29/2018 SPOKE WITH ANGIE FENCL BY PHONE <br /> Date(MM/DD/YM) Signature of Owner <br /> Name of person performing inspection(please print) KYLE PITTS&SETH ANDERSON <br /> Cerfificatlon: <br /> Installer Professional Engineer <br /> X Maintenance Provider Environmental Health Specialist <br /> i National Association of Wastewater Technicians Wastewater Specialist <br /> Other DEQ approved in writing(please describe) <br /> Certification Number: M 204 <br /> Business name: A&B Septic Service/Valley Septic Service Email a_b_septic@hotmail.com <br /> Business address:P.O.Box 444,Albany,Or,97321 Phone: 1-866-927-1156 <br /> Date of Evaluation: 12/3/2018 (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of thequalifications required to perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> 12/3/18&1/4/19 KYLE PITTS&SETH ANDERSON <br /> Date(MM/Oa/YYYY) Signature of Qualified Septic System Inspector <br /> Page 1 of 8 Updated 12/29/2016 <br />