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2 3 -00g5-35 Avrf-} <br /> Evaluation Report for Onsit I� <br /> Existing Systemp <br /> Wastewater Systems EN 6 2023 <br /> —41 State of Oregon Department of Environmental Qualitystmo of Oregon MARION COUNTY <br /> Deportment e, Onsite Program BUILDING INSPECTION <br /> ETM ' 165 East Seventh Ave, Suite 100 <br /> Quality <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 /> http://www.oregon.covideq/Residential/Paqes/Septic-Smartaspx. <br /> Septic System Owner-Provided Information: Y <br /> // / Telephone: 6 3 5 70 33g <br /> Property Owner(s)(Sellers): �f � �K���.� p <br /> Site Address:25537City: <br /> 25537 Taylor Park Rd JQ Lyons Zip Code:97358 <br /> � <br /> County: Marion Lot Size: a t U Acres/ quare Feet(circle units) <br /> Legal Description: 5 e - a_lb& <br /> Age of wastewater treatment system / j, (years) Is there a service contract for system components? /Y G <br /> Date the septic tank was last pumped'/ please attach receipt if available) <br /> Number of people occupying dwelling a If unoccupied,for how long has it been vacant? <br /> Was this section completed by the evaluator because owner or agent was unavailable? ')11 .6 l <br /> The above information is trye 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 /> ❑✓ Installer ❑ Professional Engineer <br /> ❑ Maintenance Provider D Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 1-2290 <br /> Business name Carl's Septic LLC Email eric.carlsseptic@gmail.com <br /> Business address 4742#147 S Liberty Rd, Salem, OR, 97302 Phone503.910.6329 <br /> Date of Evaluation:9/26/23 (MM/DD/YYYY) <br /> I 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 /> 9/26/23 [Digitally Signed Eric Zade] <br /> Date(MM/DD/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />