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{PECE NE* <br /> Existing System Evaluation Report for Onsite AUG 12 2024 <br /> Wastewater Systems <br /> DEO State of Oregon Department of Environmental Quality <br /> ;mat Onsite Program <br /> 165 East.Seventh Ave, Suite 100 <br /> matity <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): Neil & Kirstin Jorgenson Telephone: <br /> Site Address: 7486 Mt Angel Hwy NE City: Silverton Zip Code:97381 <br /> County Marion Lot Size: 11.95 Acres/Square Feet(circle units) <br /> Legal Description: 061 W21 D000100 <br /> Age of wastewater treatment system unk (years) Is there a service contract for system components? no <br /> Date the septic tank was last pumped 8-2-24 (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 /> Businessname 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: 8'2'24 (MIAIDD/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 /> 8-2-24 <br /> Date(MM/DD/YYYY) Signatu of i ed Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />