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61712/J2V-1 <br /> {C_ e, <br /> l`.�� ED <br /> Existing System Evaluation Report for Onsite AUG 20 2024 <br /> Wastewater Systems <br /> DEQ State of Oregon Department of Environmental Quality <br /> SibitatOrecpt Onsite Pro ram <br /> napaienoncat 9 <br /> 165 East Seventh Ave, Suite 100 <br /> Quality <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 /> http://www.oregon.gov/deg/Residential/Pages/Septic-Smart.aspx. <br /> Septic System Owner-Provided Information: <br /> Property Owner(s)(Sellers): `1-110oStTe iSorV Telephone: 5e)3.Z(r9.3 ' Z <br /> Site Address: 2.oirt S V6.U$ Oa- Ng' City: S u..VGL.rsv., Zip Code: 9 381 <br /> County: MJl.Q\otV Lot Size: 1S A c2.FS Acres/Square Feet(circle units) <br /> Legal Description: <br /> Age of wastewater treatment system ,La (years) `Is theft a seivice contract for system components? <br /> Date the septic tank was last pumped (please attach receipt if available) <br /> Number of people occupying dwelling C If unoccupied,for how long has it been vacant? <br /> Was this section completed by the evaluator because owner or agent was unavailable? <br /> The above information is true and to the best of my knowledge. <br /> • <br /> 20 z'i <br /> Date(MM/DD/YYYY) Signature of Owner,or agent if present <br /> • <br /> Name of person performing evaluation(please print): VIc.," C. CDtM (u LA-6 �.�-C <br /> Certification: <br /> g] Installer ❑ Professional Engineer <br /> ❑ 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: 3 (2, ', <br /> Business name ( ( pytc, udir U-L Email NyC )((LUL\.‘,6,e-N I({/ VVv,‘;` lOvn <br /> Business address _ r6Dy CV, I o f Gf oQ z . Phone coy.-9 6c u i <br /> Date of Evaluation: ©1/1/1`t6,0 Z (MM/DD/YYYY) <br /> I hereby certify,by my signature,that I meet all of the qualifications require o perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to OAR 340-071-0155. <br /> O N1 202 , <br /> Date MM/DD 'Sie.ture of ed Septic System Evaluator <br /> ( Qu P <br /> Page 1 of 8 Updated 12/29/2016 <br />