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• <br /> MarionCounty EXISTING SEPTIC SYSTEM DESCRIPTION <br /> OREGON <br /> •Please answer the following questions as completely as possible, and to the best of your knowledge. <br /> 1. ygur existing septic system consists of(check all that apply): <br /> Septic Tank 0 Disposal Trenches 0 Capping Fill 0 Sandfilter <br /> 0 Seepage Bed 0 Cesspool or Pit 0 Unknown <br /> 0 Other (Describe) <br /> 2. When was your septic system installed? /% 8 ((,0 !ear <br /> .errnitNumber)._. . <br /> 3. Tank material: 0 Concrete 0 Steel 0 Plastic� or Fiberglass 0 Unknown <br /> 4. Septic tank volume(in gallons) Jj Q Op <br /> 5. When was the septic tank,last pumped? Attach receipt if available. <br /> 6. Number of disposal trenches o2 <br /> 7. Total length of disposal trenches (in feet) <br /> 8. Do you propose to use the existing septic system? Yes,' No❑ <br /> • <br /> 9. Is your septic system currently in use? Yes 0 No) If no, date of last use 7/(Y/710,-.71(j <br /> 10. If the septic system currently serves a dwelling: i92C.riv -p //V 24/2e 5 • <br /> How many bedrooms are in the dwelling? How many people occupy the dwelling? <br /> 11. How many bedrooms will be in the proposed dwelling? 3 How many occupants? 5 <br /> 12. If the septic system serves a business: <br /> How many total employees are there? <br /> Type of business 4///1- <br /> 13. Is there a proposed change of use of your structure(home or business)? Yes 0 No <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 knowled•e. <br /> y/7/92/ i- . `Gf' <br /> (Date) Sign. e ofPrope • e of eg.lyAuthorized Representative <br /> Office use only: Record of existing system: Yes 0 No 0 Attached 0 Datelssued <br /> PermitNumber Certificate of Satisfactory Completion Issued: Yes 0 NoD Initials <br /> Other file information: <br />