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. : :.• : „„ „ •• • • •• -• • ••• •• ••• ••• ••• •• ;•• •• • .: : ;I Oregon Department of Environmental Quality • . . •• • Previous two years of maintenance records are available E]Yes ONo If you answered"No,"please;explain below• !.;• • : :.• :: . . ..„ •.: : . " • " • „ „ „ .. •. •••. .• •• -• • -•• • • •• ••• . 0; Previous two years of Maintenance records are attached to this.:form DYes EINo If you answered"No,"Please explain below: • • • • • • Additional •;; ]; :'" -• • ; . .„. . . : : • •••• • • . . . . •• •• • -- •• ••• •• ••• ••• •• •• . . •• .• ;; • • • •• •• • • •• • 8 Please attach a copy of the following items to this form Contact the DEQ,or the local Health Department to locate these items. „ • • The septic system permit(s)to this form,if available • The as-built drawing(s)to this forin,if available •• • • Tbe Certificate of Satisfactory Completion to this form,if available • • Additional Comments:;; „ „ :-• ••• •• • ”- • " • " " . . " •; • ••• •• • • ": • • „ , • :: •-• -• ;; 9. Provide a Site Plan !! !! !!! !! • provide a sketch of the complete system(show only system components that were Please . :• ::• evaluated)on page 8 of this form,if aeopy of the original"as-built"drawing is not available „ . • Please provide a sketch of the complete system on page 8 of this form if the orig.nal"as built" drawing is not accurate or representative of the existing Systein. • If theoriginal"as-builf'drawing is available for copy,and the original appears to be accurate and representative of the existing system,write"see attached as mit on page 8 of this form, ;, ;; ;; ; • redrawing the system is unnecessary,;ii i :; • • • • Additional Comments: . . . . . . : . . . • . . . . . . . . . • ••• " • • • Disclaimer: i; i; ;;; . . This;evaluation reportdescribes the septic system as it exists on the date of evaluation and to the extent that components and operation of the system are reasonably observable.DEQ recognizes „ . that this evaluation report does not provide assurance or any warranty that the system will operate . ; properly in the funire. . . . . . . . . . . . . 1. Thereby Certify,bymyisignature;itha:the above information and the plot plan on the next page of this forth are accurate and true to the best of my knowledge Aejl. . Da e SignatureO Qualified Septic System Evaluator • : . : . .• . : : : : ::• • • • . . . . • -- • • • • •• • . • • •• 1 H Page 7 of • • . . . . • •• • . . . . . . : !! !! !! !!i !! !! !! !! - !! ! !! ! • . . !,: ,„, „„ - •