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a3- 1o9,1) <br /> ECE[VE <br /> Existing System Evaluation Report for Onsite <br /> AUG 212023 <br /> Wastewater Systems MARION COUNTY <br /> DEQ BUILDING INSPECTION <br /> State of Oregon Department of Environmental Quality <br /> State <br /> Depement of Onsite Program <br /> 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 <br /> visit:http://www.oregon.govideq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Donovan Sippel Telephone: (Sa )SSI -083 <br /> Site Address: 5756 Fruitland Rd NE City: Salem Zip Code: 97305 <br /> County: Marion Lot Size: 12.73 Acres/Square Feet(circle units) <br /> Legal Description: 072W28BA00300 <br /> Age of wastewater treatment system 39 (years) Is there a service contract for system components? Alo <br /> Date the septic tank was last pumped 9/14/Z3 (please attach receipt if available) <br /> Number of people occupying dwelling 15 If unoccupied,for how long has it been vacant? <br /> Was this section completed by the evaluator because owner or agent was unavailable? <br /> The above information is true 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): Daniel N Shafer <br /> Certification: <br /> ❑ Installer ❑ Professional Engineer <br /> Maintenance Provider ❑ Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other: DEQ approved in writing(please describe) <br /> Certification Number: M466 <br /> Business name Santiam Septic & Drain Email office@santiamseptic.com <br /> Business address 2829 Ridgeway Dr SE Phone 971-354-1280 <br /> Date of Evaluation: 08/16/2023 (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 /> 08/16/2023 n r <br /> Date(MM/DD/YYYY) Signature of Qualified Septic Sy tem Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />