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a�rari[m EXISTING SEPTIC SYSTEM DESCRIPTION <br /> OREGON <br /> Please answer the following questions as completely as possible,and to the best of your knowledge. <br /> 1. Y. existing septic system consists of(check all that apply): <br /> Septic Tank ❑ Disposal Trenches ❑ Capping Fill ❑ Sandflter <br /> ❑ Seepage Bed ❑ Cesspool or Pit 0 Unknown <br /> ❑ Other (Describe) • <br /> 2. When was your septic system installed? I o ! 2 /0-7 O( - w 73 9 <br /> 3. Tank material: fit Concrete 0 Steel ❑Plastic or Fiberglass ❑ Unknown <br /> 4. Septic rank volume(in&lions) <br /> 5. When was the septic tank,last pumped? � Attach receipt if available. <br /> 6. Number of disposal trenches 1 <br /> 7. Total length of disposal ireuches(m feet) I/6 b' <br /> 8. Do you propose to use the existing septic system? Yes No❑ <br /> 9. Is your septic system currently in use? Yes)Z, No❑ If no,date of last use <br /> 10. If the septic system currently serves a dwelling: • <br /> How many bedrooms are in the dwelling? Li How many people occupy the dwelling? <br /> 11. How many bedrooms will be in the proposed dwelling? )" How many occupants? <br /> 12. If the septic system serves a business: rl o <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 0 No ' <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 /> (,f Z1l2 �( L Chh bar \'ZM J&TC cXC4124VO"YI <br /> (Date) // Signature of Property OamerorLegaliy Authorized Representative <br /> Office use only: Record of existing system: Yes 0 No 0 Attached 0 DateIssued <br /> PesmiitNumber Certificate of Satisfactory Completion Issued: Yes El No0 Initials <br /> Other file it r= <br />