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10°q3 f -ZP'za <br /> Nord-.1 or< LO <br /> rQ EXISTING SEPTIC SYSTEM DESCRIPTION <br /> �c4w,r� <br /> OREGON <br /> Please answer the following questions as completely as possible,and to the best of your knowledge. <br /> 1. Your existing septic system consists of(check all that apply): <br /> Septic Tank b Disposal Trenches 0 Capping Fill 0 Sandfilter <br /> ❑ Seepage Bed ❑ Cesspool or Pit 0 Unknown <br /> Other (Describe) <br /> 2. When was your septic system installed? <br /> (Date) (PermitNumber) <br /> 3. Tank material: [Concrete ❑ Steel 0 Plastic or Fiberglass ❑ Unknown <br /> 4. Septic tank volume(in gallons) ICY 1)5 <br /> 5. When was the septic tank, last pumped? 12 r 2-; <br /> ILO Attach receipt if available. <br /> 6. Number of disposal trenches -Z— <br /> ‘ <br /> 7. Total length of disposal trenches (in feet) I k. <br /> 8. Do you propose to use the existing septic system? Yes No❑ <br /> 9. Is your septic system currently in use? Yes ❑ No g If no, date of last use <br /> 10. If the septic system currently;serves a dwelling: <br /> How many bedrooms are in the'dwelling? How many people occupy the dwelling? <br /> 11. How many bedrooms w will be in the proposed dwelling? I How many occupants? <br /> 12 If the septic system serves a business: <br /> How many total employees are there? <br /> Type of business <br /> 13. Is there a proposed change of use of your structure(home or business)? Yes 0 No❑ <br /> If yes,please explain <br /> 14. Provide a plot plan(sketch) on the reverse side of this form showing the best estimated or actual <br /> measurements that locate the existing septic tank and disposal trenches,property lines, easements, <br /> existing structures, driveways, and water supply.Indicate the direction of north. If you are proposing to <br /> replace the septic system, indicate the test hole location. <br /> By my signature, I certify that the above information and the plot plan on the reverse side of this form are <br /> accurate and true to the best of my knowledg . <br /> aiagh.e, ci W <br /> (Date) Signature of Property Owner or Legally Authorized Representative <br /> Office use only: Record of existing system: Yes 0 No 0 Attached 0 Date Issued <br /> PennitNumber Certificate of Satisfactory Completion Issued: YesO NoD Initials <br /> Other file information: <br />