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2 2 - 60 qu---11-t <br /> Existing System Evaluation Report for Onsite <br /> • <br /> Wastewater Systems <br /> . . , <br /> State-of-Oregon Department of Environmental Quality <br /> Onsite-Program <br /> wrqn'ne'Aa' 165 East Seventh Ave,Suite 100 <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 /> Visithttp://wwW.bregpmgovideq/Residential/PagesiSeptio-StriartOspX <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers):,SteyA• P:,:lpe-c•evIS4-t;v1 Telephotie:--;595-NfA 304/ <br /> Site Address: 115 15 -Erief5Petvi (2-vi City: Sv Zip Code:el7Yrt <br /> Cottnty: Mcvtisit) Lot Size: 11- 6.-W).es Square Feet'(cirele units) <br /> Legal Description: W05 49000" -e20 <br /> Agc Of Wastewater treatment system .(yearS) Is there a service contract for system-components? 40 <br /> Date the septic tank was last pumperIS-1.-';-,--- (please attach receipt if available) <br /> Number of people ocetrpyierg.dwelling If unoccupied,for how long.has it been vacant? N/A- <br /> Was this section completed by the evaluator because owner or agent was unavailable? Ye _ <br /> TiAe.Aboveinformation is true And to the best of my knowledge. <br /> t,C5"-•041 ):0x3 <br /> Date(MM/DDNYYY) Signature of Owner,or agent if present <br /> Name.of person performing-evalundon(please print): Jeremiah HOMUtciff <br /> Cerilficatiun: <br /> • <br /> O. Installer 0 Professional Engineer- <br /> ': Maintenance Provider Environmental Health.Specialist <br /> 0 Natiorial Assoeiation of Wastewater Technicians. P Waste Water Specialist <br /> O Other:DEQ approved in writing(please describe) <br /> Certifkation Number f RI962 <br /> Email Business name Farmers Septic Companyfarrilerssepticco@gmait.coM <br /> Business-address PO 186x 1392,:Silverton,OR 97381 Phone5073-3344 <br /> Date of Evaluation:Ceic.<•••09-'?in a). :(MMIDDlyyYyj <br /> I hereby certify,by my signature,thin'meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in theistate of Oregon pursuant to.OM 340-071,0155. <br /> • ' (>4 0'1-as+) -7?› ( 2efrre-141, 4/407-1 <br /> Date(MM/DDNYYY) 1 Signature Of Qualified *c S 0 <br /> ystem Evaluator <br /> Page 1 of 8 Updated 1.2/29/20 6- <br /> . <br /> 1 <br />