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.. .. ... . . .. .. ... .. ... ... .. .. .. ... .. . .. .. .... .. .. ... .. . .. .. ... .. ... .. .. .. .. ... .. . .. .. .. .. .. .. ... .. . . .: .. .. ... .. .. .. .. .. .. . .. .. ... .. . .. .. ... .. ... ... . .. .. ... .. . . .. ..... .. .. ... .. . .. .. .. .. ... ... .. .. . ... . . . .. , ..... EcEvE .. .. ... .. . .. .. ... .. ... ... .. .. .. .. .. . .. .. .... 2E02cio 1T ijN. iLDM2N2sp, MAOION COUNT*/ ".'.---'-. .- i Existing System Evaluation Report for Onsrce i, INAGR 1 . ,,, ,, Wastewater Systems Hi i: :: i: --.,- .4tae. • : i ii i! . i ! DEQ ...._ .: State of Oregon PeparOner4 of Environmental Quality . . Onsite Program - ! i 1 ! ' ! . • - ErP411°-1"ent1. 1-65 East$eventh Ave, Su 165 Ogee, QR 97401 i Please answer thefollOwing questions completely.Do not leave any blank responses.Write unknownif Oregon unknown Refer taiOregAdministrative Rule 340-071-0155 for more information, and please visit . . .. .. .. .. .: ... ... .. ... .. ... .. . .. :. . .. ..... htto://www.oregoit govidealResidential/Paes/Septic-SmarLaspx. .. :. .. .. .. ... ... ... ... ... . - : •.: Septic Systeni;Owner-I'rovided Information: : ; ; : •.: • - . .. •: :: !Property Owner(s)(Sellers) ,jfC.b7f Cal4e.ii. : :: ! -:,. Telephone:g3/-,2ó/- 7f2.3 Zip Code:193 VC Site Address: 11P, /1.-%.5,4'.'71-4rn./114,y 51_-_-:: City.: 6- ofeL.0 ! i County: ,'i,./ ,0,6,1:03-7!i :: ::: Lot Size: "CP 1-6 :( /Square Feet(circle units) .. _ Legal Description:t)7ri.-4-c--27.3-e--- -: • .- -• ::::: Age of wastewater treatment system a A k(years) Is there a service contract for system components? /1.0 Date:the SeptiC"tank Was:last 3/5/2-1 (please attach receipt if available) .. . Z . .. .. . .. ... ... ... pumped /, .. .. .. .. . ..„.. ... ... ... ... ... .. .. .. . .. .. .. ,.... Number of people occupying dwelling ' C... ;: If unoccupied,for how long has it been vieantlrost-r----i _ .. .. .. .. .. ... ... ... ... ... ... ... .. .. ..... • ] ].:. ]. Was this section completed by the evaluator because owner or agent was unavailable? y&..s The above infOrmatio is true and to the best of:My hnoWledge. i ,: •• .: i •:..! •!.! ••H•• !.! ••: i.:0 1.• .e:-c. ,• 74 ::: : „ ::: :: :: :i : ---7:7 , 7/1:7------'.• . .. .. .. .. .. .. . . . . . . __ .. .. .. . • Date:(MM/DIVYYYY):! :; i :: : : :, Signature of Owner,or agent if present .. .. .. .. .. .. .. ... ... .. ... ... . .. ... .. . .. . ... . - - . :. .. .. .. .. .. .. ... ... ... ... ... . . ... .. . 0.. _ . ... . .. .. . •:E •-:•.: Name of person performing evaluation(please print): :F--zo..;J ArSo/9 . .. .. .. .. .. ... ... ... ... .. , - . .. .. .. .. . ... .. . ... .. .. ... . .. . .. . . . ..... .. .. .. .. . .. ::. ... .. .. ... . . .. : •. . Certification: : .. .. .. .. . ... ... ... ... .. .. ... .. .. . . .. . ..... Installer [j':: :: :: ; : !! :i Professional Engineer 1 ::Ins0 . .. .. .. .. . ... ... ... Maintenance Provider : i: : : 0 Environmental Health Specialist National Association of Wastewater Technicians : ' El Waste Water Specialist 0 iOther:DEQ approved in writing(please describe) • - Certification Number: 3 72-2 7---- . . Busiess name:Al.-CO/7 ::: -;....i"11./ e.. Z-(...._ - Email • •• •- •• •• •• ••• • •- Business address no 60 0 ',.1'J54.1--/ ,„11,/c-r7, 2 0• :‘ 53': .•eti, i Phone5/03--:09: -4/9. -4- /7: . . .. . Date?of Evaluation: 46:0 • • .. .. .. .. .. ... ... ... .. ... .. ... . . . .. . .. . . , .. .. .. .. ... ... . .. ... .. ... I hereby certify,by my signature,that I meet all of the qualifications required to perform onsite wastewater system evaluations in the state of Oregon pursuant to OAR 340-074-01 :. . , .„ .. :,.., : „ :: :: :: :: ::: ::: ::: : :- ::: ::: : :: .: :: :: . • •- :: ! .60-!3 '0... 5::;2-fH'.21 ! ! Date . . 00,4 D : ; :: :: :: - Signature of Qualified Septic System Evaluator .. . .. .. .. ... .. .. .. .. . ... . .. . . . . . - - -- - -- - -• . . .. .. .. . .. .. . . . ... . __ .. .. . : - --- - -- - :: • . .. . Page 1 of 8 I Updated 12/29/2016 .. . .. .. .. . . .. .. .. . .. . .. . .. . .. .. . . .. .. .. .. ... .. .. .. .. . ... . .. .. .. . .. .. .. . . .. .. .. .. .. .. ... .. .. .. .. ... . .. . . . .. .. . . . .. . . .. ... .. . .. .. . ... . .. .. .. . .. .. .. . • • • ••