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Cmgon flOpfirtotoot of Eff4roomental Comfit I. General System Information The Existing System Evaluation Report form=Mins 8 pages.Some of the questions on this form may not pertain to the system;being evaluated,as there are many system designs.If you(the septic systein evaluator)are unable to answer any of the questions on this form please indicate,hi writing,why this information was not available at the time-the eValuation was completed. The existing septic system consists of(check all,that apply): S40.0 Tank 0 Cesspool II Dosing Tank . 7.J Disposal Trenches/Leach Lines Multi-compartment Tank • Capping Fill Seepage Bed Sand Filter D. Other Note;Cesspoolstimy he used only ta serve eXisting sewage- karIS and if failingonly be replaced with a seepage,pit system on lots that are too small to accommodate a standard system or other alternative onsite system. There is a permit for the septic system :Yes i o DUnknown • • Perrait.Nutitber(s) • oiiiinids4tiSYstern installed: (1'VA') " ONO'iicard of installation date • Dates subsequent repairs or alterations: (YYYY) • Alfplurribing fixtures are connected to the septic system 7.4itiek DNa EiGriknown If you ansWered"Nor or“unirnown,"please describe below: • Additional Comments:. 2. Overall Septic System Status • Discharge of sewage to the ground surface DYes No Dlione observed • Discharge ofieWage to surface waters DYes o EjNone Observed • Sewage backup into plumbing,fixtures DYes Pi No,ElthIce.oWn • Additional Comments septic tattle In order to fully descnbe the condition of the tank;the septic tank may to be pumped.Please indicate below if the septic systemtankwaspumped during the course of this evaluation. • Septic tank was pumped during the course of this evaluation glifes DNa • lithe septic tank was NOT pumped during the course of this evaluation,please explain(e.g. ieptia*tent ownetrieelitied to'hav6 th6 tadetwiiiidet4 Page 2 of 8