Laserfiche WebLink
f -07»'r1ce-1ncizi <br /> 3c�c��soM� <br /> APR 16 2010 J <br /> MARION COUNTY <br /> Existing System Evaluation Report for Ony1ILDING INSPECTION <br /> Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality <br /> -mesons Onsite Program <br /> Iminowl 165 East Seventh Ave, Suite 100 <br /> Eugene,OR 97401 <br /> Please answer the following questions completely. Do not leave any blank responses.Witte unknown if <br /> unknown. Refer to Oregon Administrative Rule 340-071-0155 for more information,and please visit <br /> ht¢//www.oreaon.aov/dea/Residential/Paaes/Septic-Sman.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): CA t*AYE\ Telephone: <br /> She Address: 1642 to Lk CTA 2_-A ANlei.) LfCiry: . rt 4e.A-5,0,.. zip Code: gv2,S2 <br /> County: N A&y tor, Lot Size: Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system (years) Is there a service contract for system components? <br /> Date the septic lank was last pumped (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? <br /> The above 4formeliad is true sad to the best of ley Imowledge. <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing enleatton(please print): lel.\tSF\ V➢fl-N-\,a <br /> Certification: <br /> 0 Installer 0 Professional Engineer <br /> al Maintenance Provider 0 Environmental Health Specialist <br /> National Association of Wastewater Technicians 0 Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) _ <br /> Certification Number 0..12ZA <br /> Business name 4ccc-doY3W. rap-3/4:\C5 Email t i5C44ea(Cnrdab\e.Se?VACS.pom <br /> Business address "le) BcetcS-k-er 'Rd. 1-4-ha4.nor' Phone65y 1)99°- 2%1 <br /> Date of Evaluation: (3-if CR 17.011 (MM/DD/YYYY) <br /> 1 hereby certify,by my signature,that Inflmeet ma of the qualifications required to perform*mite wastewater <br /> system evaluations In tie state of Oregon astronaut to OAR 34140714155. <br /> (jet 17t1t$ VA ��� <br /> Date( ) Signature of Qualified Septic System Evaluator <br /> Pape 1 of 8 Updated 12/29/2016 <br />