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Existing System Evaluation Report for On e <br /> iir,x ._. Wastewater Systems - -JUL 27 2923 <br /> DEQ <br /> State of Oregon Department of Environmental Quality MARION COUNTY <br /> d OnsiteProgram BUILDING INSPECTION <br /> 165 East Seventh Ave, Suite 100 <br /> may <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 visit <br /> httpa/www:oregon.aov/deo/Residential/Pages/Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): Mark& Lori Huebsch Telephone: <br /> 306 Monitor Rd- Silverton 97381 <br /> Sitc'Address: City: Zip Code:. <br /> County: Marion . Lot Size: .64 Acres/Square Feet.(circle units) <br /> Legal-Description: <br /> Acres .64 <br /> Age of wastewater treatment system • (years) Is there a service contract for system components? ,no <br /> Date the septic tank was last pumped 6-27-19 (please attach receipt if available) <br /> Number of people occupying dwelling 2 if unoccupied, for how long has it been vacant?, - <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(Miy1/DD/YYYY) Signature of.Owncr,or agent if present <br /> Name of person performing evaluation(please print): <br /> Josh Hansen <br /> Ceniiicatioti: • <br /> Q lnsialler ❑ Professional Engineer <br /> ❑✓ Maintenance'Provider ❑ Environmental Health Specialist <br /> ❑ National Association of Wastewater Techniciains ❑ Waste Water Specialist <br /> Other:-DEQ approved in writing(plcase describe)' <br /> Certification Number: 38968 M271 <br /> Business name Oregon'Sewer& Drain LLC .Email josh@oregonsewer.com <br /> Business address Pa Box 1282 Silverton, OR 97381 Phone 503-874-9414 <br /> Date of Evaluation:627-19 (MM/DD/YYY-Y) <br /> l-hereby certify,by my signature,that I meet all of the qualifications required to perform ite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> 7-1-19 <br /> Date(MM/DD/YYYY) Signatur )91ie optic System Evaluator <br /> -Page 1 of 8 Updated 12/29/2016 <br />