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1. General System InfornitiOn. <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 /> iI Septic Tank _ 0 Cesspool_ <br /> 0 Dosing Tank 0 Disposal Trenches/Leach Lines <br /> LI fmtiiticompartEnent Tank Capping Fill <br /> D Seepage Bed .0 Sand Filter <br /> -Other.: <br /> Note:.Cesspools maybe used only to serve existing sewage loads and iffailing-Onfylie:teplaced-with <br /> a seepage pit systemon lots that are too small to accommodate a Standard.sySterritir.other alternative <br /> onsite systena.. <br /> There is-a permit for the septic system .-ZYeS 1:]No OUnknown <br /> • Permit NuMber(s).. , <br /> • Year'original septic system installed:- (YYYY) ciNo rdcoed2Of installation date. <br /> • Dates of subsequent repairs or alterations: 1979 (YYYY) <br /> • All.phonbjng fixtures are conneeted-telfte septic system glYOs : No• LitTril&town <br /> If yoh'ansviereeNo".or"taiknbwri,"please describe <br /> . . <br /> . . <br /> • Additional Cominentst <br /> The permit#79,4331 was issued to allow the newer home tube connected to the original septic <br /> ..system;There-is no record of the age of the original system. <br /> . . <br /> 2. Overall Septic System Status <br /> • Discharge of-seWageto the'ground.sUrface EYes. ONO 1,/,,None obsetifecf. <br /> • Discharge of sewage to sniface.waters 0Yes ONo ./None Observed <br /> e Sewage baCkup into pluiribingfiXtures ['Nes No EjUnknoVkin <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 lank was pumped during the course Of this evaluatiOn• , <br /> Septic tank was pumped dui gig the course of this evaluation WlYes 0NO <br /> • • If the septic*lc 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 /> .. _ _ <br />