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1„,.5.klitAttlipe. <br /> REC ENE <br /> Sys <br /> ror <br /> 000.5`e <br /> , . .. <br /> MAR 292019 <br /> N COUNTY <br /> 3UILDING NSPECT1ON <br />, . <br /> Existing System Evaluation Report for Onsite <br /> Wastewater Systems <br /> -.. ,..: . stab of Oregon Department of Environmental Givallty <br /> Oltelle'Plagitin <br /> er*vogw4t1 165 East Seventh Ave,Suite 100 <br /> vow <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 /> iiiiik/Mskr.oreleti.cuMilett/Residskilint/PeggelSeotie7.SitiattnOt 1 <br /> Septic System OwnenTronidedinfonention: <br /> . . <br /> Property Owne0)(Sellers): NSW2iCA., 1-emovt, Telephone: 544,ZZ3-4155 ., <br /> Site Arldrces:21 4-ZrH. 4t:/*:07/6, lit.likitilt Atireora, Zip Coda: f7eez <br /> County: Aatim Lot Size: -11 ' 'H-::&41.1ifle Feet(citric upit. s) <br /> Legal Description:. Are.s qv./ . <br /> .401.4.*gtiiiii*r.titittairoveri :Sy.tagi), lithareitscreliteeditinatfor system components? il 0 : <br /> Date the septic tank waSinitinimpiA:g!.2:61f.,(plesise:ettailt receipt If--avii gable): .• <br /> Number of people occupying dwelling 2_ If unoccupied,for how long bas it been vacant? <br /> Was this section completed by The evaluator because owner or agent wasMinindi1141 <br /> The'a,.r k., lmetiettlstrne and to the best of my httailedge.. <br /> "1174i':. .'.' ' :. ''.;ib 'Oil ' .. <br /> Date(MIVI/DD/YYX7) Signabtre of Owner,or agent if present <br /> Name of person performing evaluation(please print): .' 1.-. "., ' <br /> dfAttlf4pattlm . <br /> El installer 0 Professkmal Engineer <br /> 2i Vein bentime.Providar El :BeVIMIMietitlaHealth Specialist <br /> 0 :National Association ofWastaWafer Technicians 0 Waste Water Specialist <br /> fl Other:DEQ approved In writing(please.describe), . <br /> CcrtificationNumber:3. 1.1.y.._____ <br /> Business name itii .Excitua. j: it F.m.di gio 1 7e <br /> , : . - <br /> Business-additsalkigJOklity:flal.-. - Ph c,:-.,50q 46 0 <br /> k_i_124._ <br /> Date of Evaluation: —?-I?''1: . <br /> ft (Ivita/DD/YYYY) <br /> I hereby certify,by my'signature,that I meet all of the qualifications.rquired to pertaiñi onsite westaWn'ter <br /> systemevaluations in the state of Oregon pursuant to OAR 340-071411.55. 1 i 4 <br /> .:.'• <br /> Date gvE,y1/DD Signature Of QualifietiSeldie., :: - .Etat- <br /> Page 1 of 8 Updated 12/29/2016 <br />