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• <br /> Ma MOO EXISTING SEPTIC SYSTEM DESCRIPTI <br /> ON <br /> [omit'; <br /> OREGON <br /> • <br /> Please answer the following questions as completely as possible, and to the best of your knowledge. <br /> 1. Your existing septic system consists of(check all that apply): <br /> ❑ Septic Tank 0 Disposal Trenches 0 Capping Fill 0 Sand-filter <br /> ❑ Seepage Bed 0 Cesspool or Pit 0 Unknown <br /> ❑ Other (Describe) <br /> 2. When was your septic system installed? Gf vikn own <br /> (Date) (Pen itNumber) <br /> 3. Tank material: ❑ Concrete lg Steel ❑Plastic or Fiberglass ❑ Unknown <br /> 4. Septic tank volume(in gallons) 5'd7EG <br /> 5. When was the septic tank, last pumped? 5- 3 / Attach receipt if available. <br /> 6. Number of disposal trenches / <br /> 7. Total length of disposal trenches (in feet) /r <br /> 8. Do you propose to use the existing septic system? Yes gi No❑ <br /> 9. Is your septic system currently in use? Yes ❑ Non. If no, date of last use / _ <br /> 10. If the septic system currently serves a dwelling: <br /> How many bedrooms are in the dwelling? 3 How many people occupy the dwelling? <br /> 11. How many bedrooms will be in the proposed dwelling? —3 How many occupants? <br /> 12. If the septic system serves a business: <br /> How many total employees are there?• — <br /> Type of business <br /> 13. Is there a proposed change of use of your structure (home or business)? Yes ❑. Nab <br /> If yes,please explain <br /> 14. Provide a plot plan(sketch)on the reverse side of this form showing the best estimated or actual <br /> measurements that locate the existing septic tank and disposal trenches,property lines, easements, <br /> existing structures, driveways, and water supply.Indicate the direction of north._ If you are proposing to <br /> replace the septic system, indicate the test hole location. <br /> By my signature,I certify that the above information and the plot plan on the reverse side of this form are <br /> accurate and true to the best of my knowledge. <br /> 7% z/ ia7 <br /> (Date) SignatureofProp Owner or Legallyorzed�Pentative Office use only: Record of existing system: Yes❑ No❑ Attached ❑ DateIssned <br /> Permit Number Certificate of Satisfactory Completion Issued: Yes❑ No❑ T musks <br /> Other file information <br />