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Oregon Department of Environmental Quality <br /> l. General System information <br /> The Existing System Evaluation Report form contains 8 pages.Some of the questions on this <br /> form 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 /> ® The existing septic system consists of(check all that apply): • <br /> Septic Tank ❑ Cesspool <br /> • Dosing Tank y Disposal Trenches/Leach Lines <br /> 0 Multi-compartment Lank ❑ Capping Fill <br /> • Seepage-Ded• ❑ Sand Filter <br /> Ei Other <br /> • <br /> Note: Cesspools may be used only to serve existing sewage loads.and if ta,iling'only be replaced with <br /> a seepage pit system on lots that are too small to accommodate a standard system or other alternative <br /> onsi.te system. <br /> There is a permit for the septic system [ Yes ❑No ❑Unknown <br /> A PerrnitNumber(s) "5-I 113 <br /> 6 Year original septic-system installed: )9$3 (YYYY) ❑No record of installation date <br /> a Dates of subsequent repairs or alterations: lAstl uvt (YYYY) <br /> a All plumbing fixtures arc connected to the septic system f Yes ❑No Jnknoivn <br /> •If you answered"No"or"unknown,'please describe below: <br /> ethluttisia Dap, c,ete. 0,4 kil <br /> • <br /> ® Additional Comments: <br /> 2. Overall Septic Systeni Status <br /> • Discharge of sewage to the ground surface ❑Yes Nino None observed <br /> m Discharge of sewage to surface waters [Yes RICro l `None observed <br /> o Sewage backup into plumbing fi attires ❑Yes [AO ❑Unknown <br /> 9 Additional Comments: <br /> �. 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 sr as pumped during the course of this evaluation. <br /> e Septic tank was pumped during the course of this evaluation ❑Yes 1ZNo <br /> a if the septic tank was NOT pumped during the course of this evaluation,please explain(e.g. <br /> " septic system owti.er declined to have the tank pumped etc): <br /> Page 2 of 8 <br />