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(k-bt5 (-120 <br /> Existing System Evaluation Report for Onsi <br /> Wastewater Systems L 0 VIE <br /> DEA <br /> State of Oregon Department of Environmental Quality MAY 16 2019 <br /> ocpartmemi Onsite Program MARION <br /> Envinxirentai Cluati <br /> 165 East Seventh Ave, Suite 100 UILDING P��o� <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 /> http//v,ivw orecton:gov/deq mrt: <br /> /Residential/Paaes/Septic-Saasox: <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Patricia Hall "Telephone: <br /> Site Address: 5961 Towne Dr city: Silverton Zip Code:97381 <br /> County: Marion Lot Size: 2.08 Acres/Square Feet(circle units) <br /> Legal Description: Powers Creek Estates; Lot 8,Acres 2.08 <br /> Age of wastewater treatment system 46 (years) Is there a service contract for system components? no <br /> Date the septic tank was last pumped 5-1-19 (please attach receipt if available) <br /> Number of people occupying dwelling 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 /> •Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Josh Hansen <br /> Certification: <br /> ❑✓ Installer 0 Professional Engineer <br /> ❑✓ Maintenance Provider ❑ Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians 0 Waste Water Specialist <br /> O Other: DEQ approved in writing(please describe) <br /> Certification Number: 38968 , M271 <br /> Business name Oregon Sewer& Drain LLC Email Josh@oregonsewer.com <br /> Business address PO Box 1282 Silverton, OR 97381 phone 503-874-9414 <br /> Date of Evaluation: 5-1-19 (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> 5-8-19 <br /> Date(MM/DD/YYYY) Signatur of I ified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />