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; <br /> � 1 <br /> Existing System Evaluation Report for Onsite <br /> Wastewater Systems -E <br /> DEQ J <br /> State of Oregon Department of Environmental Quality `-� MAY 1 6 2019 <br /> Onsite Program <br /> okargy <br /> 165 East Seventh Ave, Suite 100 MARION COUNTY <br /> Eugene, OR 97401 BUILDING INSPECTION <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 fir more information, and please <br /> visit:http://www.oregon.gov/deq/Residential/Pages/Septic-Smartaspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Maly Herr <br /> Telephone: 503-871-1603 <br /> Site Address:5925 State St. S.E. Salem 973/7 <br /> City: Zip Code: <br /> County:Marion Lot Sue: 19.557 Acres/Square Feet(circle units) <br /> Legal Description: T 7, R 2, WM, SECT 28, TL R23755 <br /> Age of wastewater treatment system 11 (years) Is there a service contract for system components? No <br /> Date the septic tank was last pumped5/12/2016 (please attach receipt if available) <br /> Number of people occupying dwelling L If unoccupied,for how long has it been vacant? <br /> Was this section completed by the evaluator because owner or agent was unavailable? Yes <br /> The above information is true and to the best of my knowledge. <br /> 05/09/2019 (� /iL <br /> Date(MM/DD/YYYY) Signature'of Owner,or agent if present <br /> Name of person performing evaluation(please print): Mitchell Padilla <br /> Certification: <br /> ❑ Installer <br /> ❑ Professional Engineer <br /> ❑ Maintenance Provider - ❑ Environmental Health Specialist <br /> ❑✓ National Association of Wastewater Technicians <br /> 0 Waste Water Spec;alist <br /> Other:DEQ approved in writing(please describe) <br /> Certification Number: NAWT#123761TC <br /> Business name King's Pumping Service Email kingspumping@gmail.com <br /> Business address P.O.Box 1037, Dallas, OR 97338 Phone503-831-0104 <br /> Date of Evaluation:05/09/2019 <br /> (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to pe orm onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. ' r <br /> 05/09/2019 <br /> Date(MM/DD/YYYY) Signature of Qualifidd Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />