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Oregon Dejartment of Environmental Quality • 1. General System Information . The Existing System Evaluation Report form contains 8 pages.Some of the questions On this . form may not pertain to the system being evaluated,as there are many.system-designs.If you(the . . septic system evaluator)are unable to answer any of the questions.on this form please indicate,in writing,why this information was not available at the time the evaluation was completed. • The existing septic system consists of(check all that.apply): OSeptic Tank • Cesspool Dosing Tank - • .Disposal Trenches/Leach Lines ❑ Multi-compartment Tank Capping Fill . • ❑ Seepage Bed ❑ Sand Filter . • ❑ Other - • Note:Cesspools may be used only to serve existing sewage loads and if failing only be replaced with a seepage pit system on lots that are too small to accommodate a standaid system or other alternative onsite system. There is a permit for the septic system ❑Yes ❑No [Unknown • •- Permit Number(s) • - • • • Year original septic system installed: • (YYYY) • ❑N9 record of installation date • • -.Dates of subsequent repairs or alterations: (YYYY) • • All plumbing fixtures are connected to the septic system -011Yes ❑No ❑Unknown If you answered"No"or"unknown," lease describe below: +"( SGt . bum • Additional Comments: • . ` • • . • 2. Overall Septic System Status • • • Discharge.of sewage to the gr)und Sorfac c, llYes rgNo ❑None observed • • Discharge of sewage to sure'waters 'Dyes [ _lo ❑None observed . • Sewage bac 1 ip into bmbing ,t�s ❑Yes to a❑Unknown • • Additional Gents: . . 3. Septic tank. • i • , In order to fully escribe.lie condition of.the tank,the septic tank may need to be pumped.Please indicate below if the.,,svtic system tank was pumped during the'course of this evaluation. • -Septic tank was plumped during the course of this evaluation %Yes ❑No • • If the septic tar3ic was NOT pumped during the course of this evaluation,please explain(e.g. septic cyst ,caner declined to have the:tarik pumped etc): . ' . • • • Page2of8