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""°" EXISTING SEPTIC SYSTEM DESCRIPTION OREGON Please answer the following questions as completely as possible, and to the best of your knowledge. 1. Y ur existing septic system consists of(check all that apply): Septic Tank 0 Disposal Trenches 0 Capping Fill 0 Sandfilter ❑ Seepage Bed 0 Cesspool or Pit ❑ Unknown ❑ Other (Describe) 2. When was your septic system installed? I o /2 /0 7 ()Co - p'/ 739 -- -- — Cp_a. )- - . - - - --. _&ern*Numbe1) _ _ ... ._ _ 3. Tank material: VI Concrete 0 Steel 0 Plastic or Fiberglass ❑ Unknown 4. Septic tank volume(in gallons) ) 500 5. When was the septic tank, last pumped? ? Attach receipt if available. 6. Number of disposal trenches 111 7. Total length of disposal trenches (in feet) L/6 O' 8. Do you propose to use the existing septic system? Yes No❑ 9. Is your septic system currently in use? Yes No 0 If no, date of last use 10. If the septic system currently serves a dwelling: How many bedrooms are in the dwelling? How many people occupy the dwelling? 11. How many bedrooms will be in the proposed dwelling? ) How many occupants? 12. If the septic system serves a business: N How many total employees are there? Type of business 13. Is there a proposed change of use of your structure (home or business)? Yes ❑ NoJ( If yes,please explain 14. Provide a plot plan(sketch) on the reverse side of this form showing the best estimated or actual measurements that locate the existing septic tank and disposal trenches,property lines, easements, existing structures,driveways, and water supply. Indicate the direction of north. If you are proposing to replace the septic system, indicate the test hole location. By my signature, I certify that the above information and the plot plan on the reverse side of this form are accurate and true to the best of my knowledge. 1 L N 100 Z(r. F)(E4174 't) (Date) / Signature of Property Owner or Legally Authorized Representative Office use only: Record of existing system: Yes❑ No❑ Attached ❑ Date Issued Permit Number Certificate of Satisfactory Completion Issued: Yes El No❑ Initials Other file information: