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• <br /> g l C R 9 <br /> JUN 16 2021 <br /> N COUNTY <br /> Marion <br /> Count!! EXISTING SEPTIC SYSTEM DESCRIP1, INSPECTION <br /> OREGON <br /> Please answer the following questions as completely as possible, and to the best of your knowledge. <br /> 1. YOd existing septic system consists of(check all that apply): <br /> Septic Tank 0 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 /> 3. Tank material: 0 Concrete heel 0 Plastic or Fiberglass ❑ Unknown <br /> 4. Septic tank volume(in gallons) 500 cT?1()( <br /> 5. When was the septic tank,last pumped? "I I, ,'S 12- k Attach receipt if available. <br /> 6. Number of disposal trenches <br /> 7. Total length of disposal trenches (in feet) 3 <br /> 8. Do you propose to use the existing septic system? Yes 2 No❑ <br /> 9. Is your septic system currently in use? Yes 0 No L2''no, date of last use, <br /> 10. If the septic system currently serves a dwelling: <br /> How many bedrooms are in the dwelling? 3 How many people occupy the dwelling? <br /> 15 <br /> 11. How many bedrooms will be • the proposed dwelling? 3 How many occupants? I <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 Ud' <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 knowledge. <br /> (Date) Signature of Property Owner or Legally Authorized Representative <br /> Office use only: Record of existing system: Yes❑ No❑ Attached ❑ Datelssued <br /> PermitNumber Certificate of Satisfactory Completion Issued: Yes[] No0 Initials <br /> Other file information: <br />