12014483 - Laserfiche WebLink

Home Browse Search

( r 1 er t<,r EXISTING SEPTIC SYSTEM DESCRIPTION �oun[t) OREGON Please answer the following questions as completely as possible, and to the best of your knowledge. 1. Your existing septic system consists of(check all that apply): 2 Septic Tank VI Disposal Trenches ❑ Capping Fill ❑ Sandfilter ❑ Seepage Bed 0 Cesspool or Pit ❑ Unknown ❑ Other (Describe) 2. When was your septic system installed? Vn kiC cc n (Date) (Permit Number) 3. Tank material: j Concrete 0 Steel 0 Plastic or Fiberglass 0 Unknown 4. Septic tank volume(in gallons) 1000 5. When was the septic tank, last pumped? Attach receipt if available. 6. Number of disposal trenches Z. O rye- 1(5 h ro 1tivvi ?J O it ' 7. Total length of disposal trenches (in feet) 45 8. Do you propose to use the existing septic system? Yes 0 No 9. Is your septic system currently in use? Yes 0 Nola If no, date of last use SS,,r -7 C ate, 10. If the septic system currently serves a dwelling: How many bedrooms are in the dwelling? How many people occupy the dwelling? rm a(1 11. How many bedrooms will be in the propose dwelling? \ How many occupants? 12. If the septic system serves a business: / How many total employees are there? �1 Type of business 13. Is there a proposed thane of use of your structure (home or business)? Yes ❑ No❑ ` If yes,please explain -to (),C1 o rl.S acec_p,r� c lO f 1 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. l!�� / > I/ (Date) / Signal re of Pr p rty Owner or Legally Authorized Representative Office use only: Record of existing system: Yes C1 No 0 Attached ❑ Date Issued Permit Number Certificate of Satisfactory Completion Issued: Yes No0 Initials Other file information: