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Ob4���-' <br /> �3 I via`� <br /> JUN 012023 t <br /> Existing System Evaluation Report for Onsite <br /> Wastewater Systems MARION COUNTY <br /> BUILDING INSPECTION <br /> v State of Oregon Department of Environmental Quality <br /> = Onsite Program <br /> 165 East Seventh Ave, Suite 100 <br /> Quay <br /> Eugene, OR 97401 <br /> Please answer the following questions completely. Do not leave any blank responses.Write unknown if <br /> unknown. Refer to Oregon Administrative Rule 340-071-0155 for more information, and please <br /> visit http:J/www.oregon.govideqMesidential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Blue Line Farms Telephone: <br /> Site Address: 11513 Selah Springs Rd NE City: Silverton Zip Code:97381 <br /> County: Marion Lot Size: 38.7 Acres/Square Feet(circle units) <br /> Legal Description: 071 W050002200 <br /> Age of wastewater treatment system 1971 (years) Is there a service contract for system components? no <br /> Date the septic tank was last pumped 5-12-23 (please attach receipt if available) <br /> Number of people occupying dwelling unk If unoccupied,for how long has it been vacant? unk <br /> Was this section completed by the evaluator because owner or agent was unavailable? yes <br /> The above information is true and to the best of my knowledge. <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Josh Hansen <br /> Certification: <br /> ❑✓ Installer ❑ Professional Engineer <br /> Maintenance Provider ❑ Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: RI 761, RM 150 <br /> Business name Oregon Sewer&Drain LLC Email Josh@oregonsewer.com <br /> Business address PO Box 1282, Silverton, OR 97381 Phone 503-874-9414 <br /> Date ofEvaluation: 5-12-23 (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to perform onsite was ater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> 5-19-23 <br /> Date(MM/DD/YYYY) Signature o • d Se ystem Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />