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f <br /> Existing System Evaluation Report for One OnektY -E C _ <br /> - Wastewater Systems <br /> JUN 10 2024 Mil) <br /> DEO <br /> State of Oregon Department of Environmental Quality IVIAIOI� COUNTYsxe a Oregon <br /> Onsite Program <br /> Eftirmnental 165 East Seventh Ave, Suite 100 BUILDING INSPECTION <br /> Otsaitty <br /> Eugene, OR 97401 <br /> Please answer the following questions completely. Do not leave any blank responses.Write unknown if <br /> unknown. Refer to Oregon Administrative Rule 340-071-0155 for more information, and please <br /> visit:http://www.oregon.gov/deq/Residential/Pages/Septic-Smart.aspx <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Peter&Jenny Shetler Telephone: <br /> Site Address: 1448 Cascade Hwy SE City: Salem Zip Code: 97317 <br /> County: MarionSize: 5.63 <br /> Lot Acres/Square Feet(circle units) <br /> Legal Description: 071W340001700 <br /> Age of wastewater treatment system unk (years) Is there a service contract for system components? n0 <br /> Date the septic tank was last pumped 6-6-24 (please attach receipt if available) <br /> Number of people occupying dwelling unk If unoccupied,for how long has it been vacant? unk <br /> Was this section completed by the evaluator because owner or agent was unavailable? yes <br /> The above information is true and to the best of my knowledge. <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Josh Hansen <br /> Certification: <br /> ❑✓ Installer ❑ Professional Engineer <br /> 0 Maintenance Provider ❑ Environmental Health Specialist <br /> ❑ National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: RI 761, RM 150 <br /> Business name Oregon Sewer& Drain LLC Email Josh@oregonsewer.com <br /> Business address PO Box 1282, Silverton, OR 97381 Phone 503-874-9414 <br /> Date of Evaluation: 6-6-24 (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> 6-6-24 <br /> Date(MM/DD/YYYY) Signature o u e ystem Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />