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r , <br /> EXISTING SEPTIC SYSTEM DESCRIPTION <br /> O R E G O N - <br /> Please answer the following questions as completely as possible,and to the best of your knowledge. <br /> 1. Your existing septic system consists of(check all that apply): <br /> vig Septic Tank F4 Disposal Trenches 0 Capping Fill 0 Sandfilter <br /> ❑ Seepage Bed ❑ Cesspool or Pit ❑ Unknown <br /> ❑ Other (Describe) <br /> 2. When was your septic system installed? 004 (7)t, --05 3.Re1 4 <br /> (Date) (PermitNumber) <br /> 3. Tank material: 71 Concrete 0 Steel 0 Plastic or Fiberglass 0 Unknown <br /> 4. Septic tank volume(in gallons) l (ccoo/sao <br /> 5. When was the septic tank,last pumped? LI-5 -2-Z-. Attach receipt if available. <br /> 6. Number of disposal trenches I Lc'c y, <br /> 7. Total length of disposal trenches(in feet) I C <br /> 8. Do you propose to use the existing septic system? Yes VI No❑ <br /> 9. Is your septic system currently in use? Yes I' No❑ If no,date of last use G, $ e*1 rr' . <br /> 10. If the septic system currently serves a dwelling: <br /> How many bedrooms are in the dwelling? How many people occupy the dwelling? <br /> 11, How many bedrooms will be in the proposed dwelling? How many occupants? <br /> 12. If the septic system serves a business: �./`4 <br /> How many total employees are there? ` <br /> Type of business <br /> 13. Is there a proposed change of use of your structure(home or business)? Yes❑ Noo • <br /> If yes,please explain • <br /> 14. Provide a plot plan(sketch)on the reverse side of this form showing the best estimated or actual <br /> measurements that locate the existing septic tank and disposal trenches,property lines,easements, <br /> existing structures,driveways,and water supply.Indicate the direction of north.If you are proposing to <br /> replace the septic system,indicate the test hole location. * $g A5 6c,IF <br /> By my signature,I certify that the above information and the plot plan on the reverse side of this form are <br /> accurate and true to the best of my knowledge. <br /> (Date) Signature of Property Owner or Legally Authorized Representative <br /> Office use only: Record of existing system: Yes❑ No❑ Attached ❑ Date Issued <br /> PejmitNumber Certificate of Satisfactory Completion Issued: Yes❑ Nor] Initials <br /> Otter file information <br />