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110 D Cti Gjad d <br /> Count!! EXISTING SEPTIC SYSTEM DESCRIPTION LY6445 <br /> OREGON <br /> Please answer the following questions as completely as possible,and to the best of your knowledge. <br /> 1. Y ur existing septic system consists of(check all that apply): <br /> (Septic Tank Disposal Trenches ❑ Capping Fill El Sandfilter <br /> ❑ Seepage Bed ❑ Cesspool or Pit 0 Unknown <br /> 0 Other (Describe) <br /> 2. When was your septic system installed? OVA ViOwvi <br /> (Date) (PermitNumber) <br /> 3. Tank material: 0 Concrete Steel 0 Plastic or Fiberglass 0 Unknown <br /> 4. Septic tank volume(in gallons) £ <br /> 5. When was the septic tank,last pumped? / I /o/2 0 Attach receipt if available. <br /> 6. Number of disposal trenches 11-- <br /> 7. Total length of disposal trenches(in feet) LI 0 <br /> 8. Do you propose to use the existing septic system? Yes.riti No❑ <br /> 9. Is your septic system currently in use? Yes ❑ No al If no,date of last use Worm bvrn-I.6d ` t j?-oZ° <br /> 10. If the septic system currently serves a dwelling: <br /> How many bedrooms are in the dwelling? 2.. How many people occupy the dwelling? 2.. <br /> 11. How many bedrooms will be in the proposed dwelling? How many occupants? 2- <br /> 12. If the septic system serves a business: <br /> How many total employees are there? <br /> Type of business <br /> 13. Is there a proposed change of use of your structure(home or business)? Yes 0 No 1 <br /> If yes,please explain <br /> 14. Provide a plot plan(sketch)on the reverse side of this form showing the best estimated or actual <br /> measurements that locate the existing septic tank and disposal trenches,property lines, easements, <br /> existing structures,driveways,and water supply.Indicate the direction of north. If you are proposing to <br /> replace the septic system,indicate the test hole location. <br /> By my signature,I certify that the above information and the plot plan on the reverse side of this form are <br /> accurate and true to the best of my knowledge. <br /> 77z /q, <br /> (Date) Signature of Property Owner or Legally Authorized Representative <br /> Office use only: Record of existing system: Yes❑ No 0 Attached 0 Date Issued <br /> Permit Number Certificate of Satisfactory Completion Issued: Yes No❑ Initials <br /> Other file information: <br /> - - 2c4-c.75673 ccs-(4 <br /> 0'7 2020 �� <br /> MARION COUNTY <br /> BUILDING INSPECTION <br />