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• " - • ! !! !! Oregon Department of Environmental Qualify !! :- ! !! ! !! !! • . .. .. .. . :: :: •:: :: :: ,,, ::: :: :: :• • : ,. : •• - • 1!, Information The SystemQenerail : i ii • . .. .. .. . .. .. ... ... ... . .. . .. . . .. The EXisting System Evaluation Report form contains 8 pages, Some of the questions on this form may not pertain to the system being evaluated,as there are many system designs.If you(the septic Sys em eVahiator)are Unable to ansWer any of the questions on this form lease indicate,in . .. .. .. . . ... ... ... . writing,why this information was not available at the time the evaluation was completed The existing septic system consist of(check all that apply):!! !! Septic Tank H !!! !! !! ! ! iii Cesspool 0 Dosing Tank,!, ,i, ;! !; ! ; El i DiSpoialiiTrenches/Leach Lines 0 Multi-compartment Tank !! !! ! :!0! Capping Fill O Seepage Iled!,, !, ,, !, ,, ! ,,0! Sand Filter 0 Other I !:! ! . .. .. .. . .. .. . .. . ... .. . .. . .. .. . . Note; Cesspools may be used only to serve existing sewage loads and if failing only be replaced with O.!,seepage system on.lots that are too small to accommodate alstandard system or other alternative . onsite system::: . .. .. .. . ... .. .. .. .. There is aperihit for the septic system 0Yes, t9No :DVAIM.Own • • Permit Number(s) . ; • Year original septic system installed: 1! -"-----7',- (YYTYY)! i a No record of installation date • Dates Of subsequent repairs or alterations:; -t ',-- (YYYY) • • All plumbing fixtures are connected to the septic system DYes No FlUnknown If you answered"No"or"unknown,"please describe below:, . .. . . ... ... ... ... .. .. .. . sii-a2c- -,- - •• • • - •• - ••• •• • - ••• • - - • - ik Additional Comments . .. .. .. . .. .. ... .. . .. .. .. . .. .. . .. .. .. . .. .. ... .. . . .. . . . .. . . . . .. .. . .. ... . . .. . .. . . .. . . • - :: - - • ::: • - - - • :: - - • 2 Overall Septic System Status • Discharge of sewage to the ground surface DYes i!EjNo FNone observed i! • Discharge of sewage to surface waters DYes, EINo n None observed • Sewage backup into phimbin. g fixtures DYes, [EN° DUnknown • Additional Comments:,,, • . .. .. .. . .. .. . ... .. ... ... .. . .. . . .. .. .. . .. .. .. ... .. ... .. .. . • ;; ;: :: ; 3 Septic tank . .. .. .. . .. . .. . .. . . . .. .. „. ii In.order to fully describe the condition of the tank,the septic tank may need to be ptumped. Please indicate below if the septic system tank was pumped dining the course of this eValuation, • * Septic tank was pumped during the course of this evaluation 2 Yes DNo I, • If the septic tank was NOT pumped during the course of this evaluation,please explain(e.g. septic:system owner declined to have the tank pumped etc): . .. .. .. . .. .. .. .. .. .. .. . .. . .. . .. . Page 2 of a !- i ... .. . . . . . .. . . .. .. . .. . . - - - •• - - - - -- - • - - - - .. .. .. .. .. .. .. . .. .. . .. . . , . .. .. .. . .. .. .. .. . . .. . .. . .. .. .. . .. . . .. .. .. . .. . . • -- -- •• • -- • - - • • - . .. .. .. . .. . .. . . .. •• . .. .. . . . . . .. . . . . .. .. .. . .. •• -- - • -- -- -- - -- -- • - • • • - - : :: :: •.: • :: :: :: :: :: : :: : .: :: - , :: : ::