8624239 - Laserfiche WebLink

Home Browse Search

don Department of EnviNnmental Quality I. General System nforination The Existing Syst-m Evaluation Report form contains 8 pages. Some of the questions on this form may not pe t.in to the system being evaluated,as there are many system designs.If you(the septic system eve,uator)are unable to answer any of the questions on this form please indicate,in writing,why this nformation was not available at the time the evaluation was completed. • The existing septi system consists of(check all that apply): Pp y): VA! Septic Tank Cesspool Dosing Tan Disposal Trenches/Leach Lines . Multi-comp.rtment Tank Capping Fill ❑ Seepage Be. ❑ Other Sand Filter Note:Cesspools may le usedonly to serve existing sewage loads and if failing only be replaced with a seepage pit system o lots that are too small to accommodate a standard system or other alternative onsite system. There is a permit for t e septic system gfres ❑No ❑Unknown • Permit Number(s) ,—LISA vLc ®t,C, • Year original septi system installed: jq (YYYY) ❑N o record of installation date • Dates of subseque t repairs or alterations: (YYYY) • All plumbing fix es are connected to the septic system ❑Yes ❑No (Unknown If you answered" o"or"unknown,"please describe below: `51• • d +0 th 414 lei 1 • Additional Comm u nts: 2. Overall Septic Sy tem Status • Discharge of sewa a to theground surface � ❑Yes NNo[]None observed • Discharge of sew.Le to surface waters ❑Yes �No ❑None observed • Sewage backup int. plumbing fixtures ❑Yes jNo ❑Unknown • Additional Comm• ts: 3. Septic tank In order to fully descri.e the condition of the tank,the septic tank may need to be pumped.Please indicate below if the se.tic system tank was pumped during the course of this evaluation. • Septic tank was pu ped during the course of this evaluation 1"/Yes ❑No . • If the septic tank w:s NOT pumped during the course of this evaluation,please explain(e.g. septic system owne declined to have the tank pumped etc): Page 2 of 8