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<br /> •••• . i'::: Oregon Department of EnViroriMerital Quality
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<br /> ... ..:' !! '•-•:; •••• Previous two years of Maintenance records are available: Dies ON° .. .
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<br /> -;; -:: ,; ::.•: :: If you answered"No,"please explain below: .: • . :-
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<br /> • Previous two years of maintenance records are attached to this form OYes ON°li •
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<br /> • - :: :•• • ::. If you answered"No,"please explain below: :•, :, , „,. . .
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<br /> " •: AdditionaliComm ents:;E:
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<br /> Please attach a copy of the following items to this form;Contact the DEQ,or the local Health
<br /> Department to locate these items.:: : •! „: '.: .! .!::'!i . ' • • ': •
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<br /> •• The zi•septic system Permit(s)to this form,if available .:
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<br /> •: The as-built diawing(s)ito this forth,if • , ::::: : •
<br /> !-: . :.: :.•: • The Certificate of Satisfactory Completion to this form,if available . •• • .
<br /> •: Additional Conaments:::: ;; :! ::, ;, !; ;; - ,;;;; • - • -- - .
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<br /> z:: ••• ; :,•:;, 54.. Provide aSite Plan :• ', :: .: ;I ,; ;; :• i! .i : , ,.
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<br /> iv Please provide a sketch of the complete system(show only system components that were . :
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<br /> ..- ::- : ;., .:• evaluated)on Page 8 of this form,if apopy of the Original"as-built"drawing is not available, , •
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<br /> • Please pro:vide:a sketch of the complete system on page:8 of this form if the original"as4built"
<br /> drawing is not accurate or representative of the existing system
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<br /> ::! ..-.: i !:,• • If the:original: as-built"drawing is available for copy,and the.original appears to be accurate and . i •
<br /> ::; •:: , - -. representative of the eXistinesystem,write"see attached as-built";on page 8 of this form,
<br /> :: :. ': '': • :i; redrawing the system is unnecessary
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<br /> . . .. .. . . . ... . .. ... ... ... . ..- : • : • Additional COnments
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<br /> .'. ::: I•li 10. Disclaimer: ;: :: -:: • :' :
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<br /> This evaluation report describes the septic system as it 6xisfS.on the date of evaluation and to the
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<br />, ':„ „:i ::; ••:: ':, extent that components'.and operation of the system are reasonably obServable.:DEQ recognizes
<br /> ilia. t this evaluation report does not provide assurance or any warranty that the system will operate•
<br /> Properly in the future
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<br /> .• ::• •• ., ., 11. Thereby PertifY,by my signature,that the above information and the plot plan on the next page of
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<br /> this are accurate true to the: best of‘ my knowledge . ... .
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<br /> ::. i:-: :.: ]•..•i'. :: Da e .• :'. i! :-. •:. - : :;: 1 Signature ofOuálifled Septic System Evaluator: • ,
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