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•• •• •'' Department Environmental Quality •• • . . . . . . . . . . General System Information " .• "" " --. • .:: " " " The Existing System Evaluation Report form contains 8 pages.;Some of the questions on this ! i! form may not pertain to the system being evaluated,as therearemany System design's.If you(the !!: septiC:system evaluator)are unable to answer any of the on this form please indicate,in questions . .•: : . : " • •• •: !! !! !! wining,why this information:was:not available at the time the evaluation was completed :• :• :• :• : :• :• •: ": •:: •:• :"• " • " " The existing septic system consists of(cheek all that apply):!!! •- M. Septic Tank ::! a: Cesspool •• D Dosing Tank !! ! Disposal Trenches/Leach Lines 0 Multi-compartment Tank 0!! Capping Fill 0 Seepage Eed::: ;:: ; 0 Sand Filter • 0 Other i H ; ; ; • • :! !: Notei Cesspools maybe used only to serve existing: sewage loads and if failing only be replaced with a seepage system on lots that are to small to accommodate aancliird system of other alternative . ;., onsite system.::: !,: :! ;: • ; !! There is aperinit for the septic system ni:Yes: 0No OLlnktiOWn . • !! I! 1 4: Permit Number(s):1!/ 7-3/3 ! i! • . : :• .; . „ !!! • Year Original septic syStem installed: (YYYY):: ! No record of installation date !! !! !! !!! • Dates of subsequent repairs or alterations: /9 (YYYY) :.• : • All plumbing fixtures are connected to the septic system 0Yes No []Unknown yoIfu answered"No"or"unknown,"please describe !! !! . . • • • •: Additional Comments::: ! . . . . : : : : • • 2 Overall Septic System Status !!! ! !! • . . . . :• : "• .•: : •• • • Discharge of sewage to the ground surface 0Yes o riNone observed • Discharge of sewage to surface waters: ['Yes [ To ['None observed 0! Sewage into plumbing fixtures [ No 0Un.kn own backup • Additional : : • . . • • • • • • : •.:: 3 Septic tank Ili :• In order tolly describe the condition of the tank the septic tank may need to be piimped.Please indicate below if the septic system tankwas pumped during the course of this evaluation tank „ , . . „ was pumped during the course of this evaluation :[ Yes 11/go • 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)::! . . !!! ;!: :! ! Pa:de 2 of 8 •. : .••:• . . . . . . „ -• . . • ••• -• - • . •:.••