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RECP:VE ' <br /> AUG 18 2022 —J <br /> fr-1:5, Existing System Evaluation Report for Onsite MARION COUNTY <br /> BUILDING INSPECTION <br /> :,-,•,-;'fat Wastewater Systems <br /> DEQ State.of Oregon Department of Environmental Quality <br /> rectlfea Onsite Program <br /> awimnmentd 165 East Seventh Ave,Suite 100 <br /> 0014 <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 visit <br /> httn://www.oregottdovideo/Residential/Pactes/Sentic-Smartaspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellets); M k ptheteex-- Telephone: 5703 .3Z 7715 <br /> Site.Address: tra, 5 City; D-e--41-0 ;f-Zip Code: ?1 3 Li <br /> County: V\ (-5\r• Lot Size: Acres/SquareFeet(circlennits) <br /> Legal Description: <br /> Age of wastewater treatment system (years) Is there a service contract for system.components? <br /> Date the septic tank was last'pumped. (please attach receipt if available) <br /> Number of people occupying;dwelling If unoccupied,for how long has it been Vacant? . <br /> Was this section completed by the evaluator because,owner or agent was unavailable? <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): <br /> Certification: <br /> g Installer E] Professional Engineer <br /> El Maintenance Provider 0 Environmental Health Specialist <br /> '0 National Association of Wastewater Technicians 0 Waste Water Specialist <br /> El Other:DEC/approved in writing(please describe) <br /> Certification Number: 3 5. 3'1 <br /> < <br /> Business name ()Ulf". CM 461 Email (y,,,,v..em <br /> 11' <br /> Business address PO 6°1-*--- <br /> IS-0 Phone 51511- Tier .... 14:,;(..,(1' t"'" <br /> Date of Evaluation: \ LSI (MMJDD/YYYY) <br /> f hereby certify,by my signature,that I meet all of the qualifications required to perform onsite Wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> Date(MM/DD/YYYY) Signature of qualified-Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />