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REC'O JUL 12 2P21 N� it Coury) EXISTING SEPTIC SYSTEM DESCRIPTION unt 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): V Septic Tank Vi Disposal Trenches ❑ Capping Fill 0 Sandfilter El Seepage Bed 0 Cesspool or Pit 0 Unknown 0 Other (Describe) 2. When was your septic system installed? Vn t•4_,,i (Date) (PermitNumber) 3. Tank material: A 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 2 0 rve- v5 ‘I)ro 1ticN+ Z� Dlif' 7. Total length of disposal trenches (in feet) `^G 8. Do you propose to use the existing septic system? Yes 0 NoX 9. Is your septic system currently in use? Yes El .�Q No14 If no, date of last use , / C `� 4,10. If the septic system currently serves a dwelling: How many bedrooms are in the dwelling? /�. How many people occupy the dwelling? r-1,D(A. 11. How many bedrooms will be in the proposed dwelling? 1 How many occupants? q 12. If the septic system serves a business: How many total employees are there? N 1�c Type of business 13. Is there a proposed change of use of your structure (home or business)? Yes ❑ No❑ If yes,please explain i a MR., i -(a�vJQ•p tq� ac��p,r 1,D ' 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. 6-) 17/ ao a i 4),,,R,(4,6,_ )4;k „ 0-1. 6_,c,\ - \-k ufrA, (Date) Signature of Propert Owner or Legally Authorized Representative Office use only: Record of existing system: Yes[I No 0 Attached El Date Issued Permit Number Certificate of Satisfactory Completion Issued: Yes El No0 Initials Other file information: