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v , i Oregon Department of Environmental Quality 1. General System Information The Existing System Evaluation Report form contains,8 pages. Some the questions on this form may not pertain to the system being evaluated,as there are many .ystem designs. If you(the septic system evaluator)are unable to answer any of the questions on t is form please indicate,in writing,why this information was not available at the time the evaluati in was completed. • The existing septic system consists of(check all that apply): 0 Septic Tank EDCesspool Dosing Tank © Disposal Trenche. Leach Lines ❑ Multi-compartment Tank 0 Capping Fill ❑ Seepage Bed 0 Sand Filter 0 Other Note:Cesspools may be used only to serve existing sewage loads and if fai ing only be replaced with a seepage pit system on lots that are too small to accommodate a standard ,stem or other alternative onsite system. There is a permit for the septic system ®Yes ❑No ['Unknown • Permit Number(s) 08-01996 • Year original septic system installed: J; p y (YYYY) ❑✓No r-cord of installation date • Dates of subsequent repairs or alterations: 05/09/2008 . (YYYY) • All plumbing fixtures are connected to the septic system gYes ON i _Unknown If you answered"No"or"unknown,"please describe below: • Additional Comments: 2. Overall Septic System Status • Discharge of sewage to the ground surface ❑Yes No None obs rved • Discharge of sewage to surface waters ❑Yes No None obsery d • Sewage backup into plumbing fixtures [Nes No ❑Unknown • Additional Comments: 3. Septic tank In order to fully describe the condition of the tank,the septic tank may need to be pumped. Please indicate below if the septic system tank was pumped during the course of thevaluation. • Septic tank was pumped during the course of this evaluation ElYcs No • If the septic tank was NOT pumped during the course of this evaluation,please explain(e.g. septic system owner declined to have the tank pumped etc): Page 2 of 8 ` i