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.:: .••••• - " - - .. .. .. .. :: :: :: :: :: :: :: :: ::: :: :: : : :;: :: : :: : ::::: ;,• .:: „ ..„ . .. .._.. .. .. .. ... .. .. . .. .. . .. . ..... H ii p i !Ft;- .t,-.;,•Al Existing::: System EvaluationRe.:pO...r, t for Onsite 0: Wastewater Systems DEQ State of Oregon Department of Environmental Quality: Onsite Program EnvftrPentql 165 East Seventh Ave, Suite 100 :: :: :: :: Owl*: :: •• Etigene, OR 97401 Please answer the following questions cornpletely.Do not leave any blank responses.Write unknown if unknown Refer to Oregon Administrative Rule 340-071-0155 for more information,and please visit htto://wwW.oregortdoVideoiRealdential/Pades/Septic-Smart'asp*. $eptie SYStern!Owner-iinviiled Information: hirr Ross ___;j: iiet (71411.10 Propertywne .••• 1 Or(s)(Sellers): i (0:, /4 jil e-r t' Telephone:50 3.7-sg)- 2 &- -,2_? - " " ' " ::• " ?-4-ziaS PP' -fri- ' • Site Address: ,-,..- il: . ,,:%.-,—-,517-5 ET_ :: :: City::Ly 0,13:: Zip Code:, 35g I z • -- • • ---- . . ..... , .. .. .. .. .. .. ... ... ... .. .. .. . . .. ., .. .. .. .. .. ... . . .. ... .. . . ..„„ ,.., : County: :! !',1:;./7 ::: :: Lot Size:: ..0 . 2. _.3 : 1C-cagSquare Feet(circle units) ..... Legal Description:eS':4/ 1;3.2.LBe003/7./.(A.'!7&/.1/51 .E././41.2: itz bgi.cc4.-314;7' 5 Age of wastewater treatment Syste.le (years) Is there a service contract for system components? ,...4-1.0 . it--ii. 1 Date the septic:tank was last piimped) .2,I (please attach receipt if available) - - .. .. .. .. .. .. ... ... ... ... ... .• vol.Lr--. . ... .. .. .. ..._. Number of people occupying dwelling ';1251-t-- ::! If unoccupied,for how long has it been viCanty2e2V-7=-7 ii• .. .. .. .. .. ... ... ... . Was this section completed by the evaluator because owner or agent was unavailable? 7&,..5 • . .. .. .. .. ... :: :: •:: ::The above information is true and to the best of my itnoWledge. : ::::: :- • A 1 11 :H EP'.W0 •./ P'.!E, il 11 III 11 1 1.--- 71. ---+—. . .. .. .. .. . .. .. ... ... ... .: .. .. .. ... .. .. . . ... . Date:(MWDDPIYYY):: :: :: :: ::: :: :: : : Signature of Owner,or agent if present .. .. .. .. . .. .. ... ... ... .. .. .. .. ... .. .. . . ... . .. .. .:.•• .:.•• Name of person performing evaluation(please print): :: IQ eerecatiOn: l , ins0,11er:: ::: ii i i ii :: :: ii : i 0 Professional Engineer 11 Maintenance Provider i; i ;: i; '; ; El Environmental Health Specialist El National:: Association of Wastewater Technicians : i El Waste Water Specialist .. .. .. .. ... ... ... ... ... ... . .. .... OiiPthOr:DEQ approVed in writing(pleasedesaribe) .. .. . .. .. ... ... ... ... ... ... ... . .. . .... . Certification Number: 3 .',..2_ ---?-4 11 i 1 1H :: : • .. • _ .. .. .. .. .. .. .. ... ... ... ... ... .. .. .. . . .. . . .... . . .. .. .. .. .. ... .. ... ... .. ... ... .. .. .. . _ . . . - ,,. • :. .. .. .. ... .. ... ... . .. ... .. .. .. Business name: 749,.... 4 5H.e';> !") ,. .3. / L-i_ .,- Email 1 / /5 Business address ":",:; et.* !;5"/ )1/,')/ •-; o'fl ?.-7--;3 ; Phone5c7.58 hi 41V-5.' • • Date of Evaluation 0:.-2..__/-6.,:.1. ...7--I'co 2(::: :: :(IVIAVDDArYyy) • - 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 340-011-01 $. .. . .•• ; / -, ';,,8'172.6, :( 1,14- Date ;• /DD signatite o Qua ed eptic System Evaluator - •• - - • - - •- •-• -.• •-• • - - - -- Ragol of 8 :: ::::: Updated 12/29/2016 .. .. .. .. . .. .. :. ... ... ... ... .. .. .. .. ._ . . ... • - - - i: i : :; i: :: !;i i: !!: :: i :.: • :: :: : :: :: :: :: :: .• . :: :: :: ::: ::: ::: :.: „: :: :: :: :: : :: ::::. :. . .. . ... .. .. ... .„ .: .. .. .. . .. .. . .. . ._..