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- , <br /> ( e.er Q d-er• joCf-t,L <br /> Oregon Department et Environmental Quality <br /> 1. General System Information <br /> The Existing System Evaluation Report form contains 8 pages.Some of the questions on this <br /> form may not pertain to the system being evaluated,as there are many system designs.If you(the <br /> septic system evaluator)are unable to answer any of the questions on this form please indicate,in <br /> writing,why this information was not available at the time the evaluation was completed. <br /> • The existing septic system consists of(check all that apply): <br /> Septic Tank 0 Cesspool <br /> O Dosing Tank Disposal Trenches!Leach Lines <br /> O Multi-compartment Tank 0 Capping Fill <br /> O Seepage Bed 0 Sand Filter <br /> O Other <br /> Note:Cesspools may be used only to serve existing sewage loads and if failing only be replaced with <br /> a seepage pit system on lots that are too small to accommodate a standard system or other alternative <br /> onsite system. <br /> There is a permit for the septic system. OYes 0No JUnknown <br /> • Permit Number(s) 465 <br /> • Year original septic system installed: 1976 (YYYY) ON°record of installation date <br /> • Dates of subsequent repairs or alterations: unknown (YYYY) <br /> • MI plumbing fixtures are connected to the septic system OYes ON0 ZUnknown <br /> If you answered"No"or"unknown,"please describe below: <br /> A trickle of water was condtantly draining Into the septic tank due to possible running toilet <br /> Unable to test for other connections <br /> • Additional Comments: <br /> The original as built and records do not match what is in the ground.Possible repair to system <br /> between now and aligned system installation <br /> 2. Overall Septic System Status. <br /> • Discharge of sewage to the ground surface °Yes ONo ZNone observed <br /> • Discharge of sewage to surface waters OYes ONo ( None observed <br /> • Sewage backup into plumbing fixtures OYes DI,loIOU:Arnow:1 <br /> • Additional Comments: <br /> 3. Septic tank <br /> In order to fully describe the condition of the tank,the septic tank may need to be pumped.Please <br /> indicate below if the septic system tank was pumped during the course of this evaluation. <br /> • Septic tank was pumped dining the course of this evaluation iYes ONo <br /> • If the septic tank was NOT pumped during the course of this evaluation,please explain(e.g. <br /> septic system owner declined to have the tank pumped etc): <br /> Page 2 of 8 <br />