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Oregon Department of Environmental Quality <br /> 1. General System.Information <br /> The Existing System Evaluation Report form contains S pages.Some of the questions on this <br /> norm may not pertain to the system being evaluated,as there are Many system deSigns.If you(the <br /> septic system evaluator)are unable to answer any of the questions on this form please indicate,in <br /> writing,why this information was not available at the time the evaluation was completed. <br /> a The existing septic system consists of(check all that apply):. <br /> [Y(Septic Tank E/Cesspool <br /> Dosing Tank Disposal Trenches/Leach Lines <br /> LI Multi-compartment Tank LI Capping Fill <br /> O seepage Bed E Sand Filter <br /> 0 Other <br /> Note,:Cesspools may be used only to serve existing sewage loads and if failing only be replaced with <br /> a seepage pit system on lots that are too small to accommodate a standard system or other alternative <br /> onsite system. <br /> There is a permit for the septic system DYes ON° T6nknown <br /> 0 Permit Number(s) <br /> a Year original septic system installed: (YYYY) DNo record of installation date <br /> * Dates of subsequent repairs or alterations: (YYYY) <br /> a All plumbing fixtures_are connected to the septic system DYes []No ! i'finkrtown <br /> If you answered No or"unknown,-please describe below: <br /> Ittitee-tt OtAtiti IfiAy <br /> Acklitional Comments: <br /> 2. Overall Septic System Status <br /> * Discharge of selvage to the ground surface DYes 12o None observed <br /> o Discharge of sewage to surface waters DYes o L.,None observed <br /> a Sewage backup into plumbing fixtures DYes El <br /> o Unknown <br /> a< <br /> a Additional Comments: <br /> 3. Septic tank <br /> in order to fully describe the condition of the tank,the septic tank may need to be pumped.Please <br /> indicate below if the septic system tank-was pumped during the course of thi± lttation. <br /> ® Septic tank was pumped during the course of this evaluation DYes NW.0 <br /> If the septic tank was NOT pumped duringthe course of this evaluation,please explain (e.a, <br /> septic system owner declined to have the tank pumped etc): <br /> Page 2 of 8 <br />