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Oregon Department of Environmental Quality <br /> 1. General System trdormattion <br /> The Existing System Evaluation Report form contains g pages.Some of the questions on this <br /> form may not pertain to they system being evacuated,as there are many systems de <br /> signs. If you(the <br /> septic system evaluator)are unable to answer any of the questions on this form please indicate.in <br /> writing,why this information was not available at the time the evaluation was completed. <br /> • The Pwisting septic system consistsof(check all that apply): <br /> x Septic Tank <br /> Dosing Tank Cesspool <br /> x Disposal Trenches/Leach lines <br /> Multi-compartment Tank <br /> Seepage Bed Capping Fill <br /> Sand Filter <br /> Other(please describe) <br /> Note:Cesspools may be used only to serve existing sewage loads and If failing only be replaced with <br /> a seepage pit system on lots that are too small to aaornrnedate a standard system or other alternative <br /> onsite system. <br /> • There Is a permit for the septic system x Yes <br /> No Unknown <br /> • Permit Number(s) 92-2619 <br /> • Year original septic system installed: 1992 <br /> (YYYY) No record of installation date <br /> ' Dates of subsequent repairs or alterations: (Yyr,) <br /> • All plumbing fixtures are connected to the septic system Yes No x Unknown <br /> If you answered'No,"or"unknown,"please describe below: <br /> NO HOME ON PROPERTY DUE TO WILDFIRE <br /> • Additional Comments: <br /> 2. Overall Septic System Status <br /> • Discharge of sewage to the ground surface Yes No x None observed <br /> • Discharge of sewage to surface waters Yes No x None observed <br /> • Sewage backup into plumbing fixtures Yes No x Unknown <br /> • Additional Comments: <br /> NO HOME ON PROPERTY DUE TO WILDFIRE <br /> 3. Septk tank In order to fully describe the condition of the tank,the septic tank may need to be pumped.Please indicate <br /> below If the septic system tank was pumped during the course of this evaluation. <br /> • Septic tank was pumped during the course of this evaluation x Yea, No <br /> • If the septic tank was NOT pumped during the course of this evaluation,please explain(e.g. <br /> septic system owner declined to have the tank pumped etc): <br /> Page 2 of if <br />