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Oregon Departmerit of Environmental Quality <br /> • Previous two years of maintenance records are available ElYes ON° <br /> If you answered'No,"please explain below: <br /> • Previous two years of maintenance records are attached to this form DYes ENo <br /> If you answered"No,"please explain below: <br /> - <br /> • Additional Comments: <br /> 8. Please attach a copy of the following items to This form.Contact the DEQ,or the local Health <br /> Department to locate these items. <br /> • The septic system permit(s)to this form,if available <br /> • The as-built drawing(s)to this form,if available <br /> • The Certificate of Satisfactory Completion to this form,if available <br /> • Additional Comments: <br /> 9. Provide a Site Plan <br /> • Please provide a sketch of the complete system(show only system components that were <br /> evaluated)on page 8 of this form,if a copy of the original"as-built"drawing is not available, <br /> • Please provide a sketch of the complete system on page 8 of this form if the original.''as-built" <br /> drawing is not accurate or representative of the existing system. <br /> • If the original"as-built"drawing is available for copy,and the original appears to be accurate and <br /> representative of the existing system,write"see attached-as-built"on page 8 of this forms <br /> redrawing the system is unnecessary. <br /> • Additional COmments: <br /> 1 a Disclaimer: <br /> This evaluation report describes the septic system as it exists on the date of evaluation and to the <br /> extent that components and operation of the system are reasonably observable.DEQ recognizes <br /> that this evaluation report does not provide assurance or any warranty that the system will operate <br /> properly in the future. <br /> 11. I hereby certify,by my signature,'that the above information and the plot plan on the next page of <br /> this form are accurate and true to the best of my knowledge. <br /> 0601-34,95 <br /> dit/reb.44.. 14;1 <br /> Date Signature of. alified Septic System Evaluator <br /> Li <br /> Page 7 of 8 <br /> 1 <br />