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- .. . 2Z ,0OS329 — fri4z� <br /> Mcounty arion EXISTING SEPTIC SYSTEM DESCRIPTION <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 /> O'Septic Tank 1Disposal Trenches 0 Capping Fill 0 Sanclfilter <br /> ❑ Seepage Bed 0 Cesspool or Pit 0 Unknown <br /> ❑ Other (Describe) • <br /> 2. When was your septic system installed? , A1 1-1 kJ_ d 9A i5 P_i f +—2 d j 2 <br /> 3. Tank material: i Concrete ❑ Steel 0 Plastic or Fiberglass 0 Unknown <br /> • <br /> 4. Septic tank volume (in gallons) i n <br /> 5. When was the septic tank,last pumped? I16 O Attach receipt if available. <br /> 6. Number of disposal trenches <br /> 7. Total length of disposal trenches (in feet) <br /> 8. Do you propose to use the existing septic system? Yes It., No❑ <br /> 9. Is your septic system currently in use? Yes E No 0 If no, date of last use <br /> 10. If the septic system currently serves a dwelling: 7pstAp 7. y 1 <br /> How many bedrooms are in the dwelling? How many people occupy the dwelling? <br /> 11. How many bedrooms will be in the proposed dwelling? 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 ❑ NoLh . <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 know edge. <br /> 11501aeR) Si:- a of Prop Owner or Legally Authorized Representative <br /> Office use only: Record of existing system: Yes❑ No❑ Attached ❑ Date Issued <br /> Permit Number Certificate of Satisfactory Completion Issued: Yes 0 No❑ Initials <br /> Other file information: <br />