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<br /> • :: :' ' —L-7. .: Existing System Evaluation Report for Onsite
<br /> Wastewater Systems
<br /> DEQ H ''.: :ii ::: .! i -' • ii . iu i :: :•.••
<br /> Department State of Oregon of EnvironmentalQualitY
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<br /> -r• -• S• ::.:Deputmeatit Onsite Program ::. : •• ••• • :: : • :•:: • .. .
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<br /> '.'! -• 1; 7 t!! 165 East Seventh Ave,Suite 100-, .. ;: .; . i ; ii ;; .•
<br /> •Etigene, OR 97401 :; i: ... • :, :: :: 1-,: : : •
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<br /> Please answer the:follOWIng:questiona cornplefely.Do not leave any Wank tesPonses Write unknown if
<br /> unknown Refer Refer tO'Oreon:Adriiinistrative:Rula 340-071-0155 for more information,and please visit
<br /> • .: 11 ritto://wWW.oregon.goV/deo/Residential/PagesISeptic-SMa rt.aspic
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<br /> Septic systenOwOr-r.rovided Information: .1
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<br /> Property Owner(sXSellers): $(i ,e) ::/34: 51-- ! : !! :; :J';; Telephone:L/2.172) .-8/447 • :
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<br /> SiteAddress:/.:71: C-•& P LA/ 5.k._ • .. :City:: 6e-i'le-j-._s 1 Zip Cod.eg,t31/4 .
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<br /> Comity: L./&i>". .4 ::. Lot Size:110 1,-3 gr...4..6 1: Acres/Square Feet(circle units) 1 •
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<br /> :: :=:Legal:Deieription:...9'3 :.2-.719 -, :i :i :; i; '
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<br /> . .. .: Age of wastewater treatment'system /y . ea ro Is there a service contract for system components? /14:9
<br /> :• •:: : Date the Septiqtankwalilast pumped / ' ,-a,(pleaSe attach receipt if available)
<br /> 497
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<br /> ;: •:: :: ::Number of people occupying dwelling 3 !i; ::. If unoccupied,for how long has it been vacant?;6127Lit ..
<br /> Was this sectiOn completed by the evaluator because owner Or agent Wits unavailable?: ve.,5 r:
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<br /> : • .:, :.11e above information is true and to the best of my ImoWledge.
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<br /> Date:.(MM/DD/YYYY)':; ;.' - . ' • ' Signature of Owner,or agent if present ;
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<br /> ;• .• ••• Name of person performing evaluation(please print): 11 ,q„,1-3': 44 gr 5 cw
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<br /> •:( ertification: :•
<br /> Installer:: 1: !i; :; : 11 1: ::: 11 0 Professional Engineer :i :. ••
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<br /> •1 • ::• ::;Igt -Maintenance Provider :• :•• i : - :! 1; 0 Environmental Health Specialist • • .
<br /> 0 .:National Association ofWastewater Technicians :, :1 0 Waste Water Specialist
<br /> • • 1:: ;=.0 :!Other.DEQ approved in writing(please describe) 1! :' :: ;:.:= 1 ' •
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<br /> •: ::; iii 1::6ertification 14Umber: :3 1712-.2. 5r--7.. ]: :.:
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<br /> .i:Business intme1-710s6;9 .<::pri ./ce4) ti:i—C.1. i imilil /".".o4.0,15--e._F0-0.-;/- 8::;./.-7
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<br /> Business address :: pi R.,?tx.57 .<17//c..957,or,; 9 7-...?6,exi:::g PhontiCal3 99.77-49V.6-
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<br /> Date of Evaluation:: /-2- a j,.2ze i (MM/DD/YYry)
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<br /> •• 1:: I hereby certify,by my;signature,thatl meet all of the qualifications required to perform Onsite wastewater
<br /> system evaluations in the state of Oregon pursuant to OAR 340-071-01:0$. : : : E• ,
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<br /> ossf •:: ••1 • :. E•Date • .D • • .: • :* :: •• Signature of Qualified Septic System Evaluator :
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