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t , <br /> Oregon Department of Environmental Quality <br /> • <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 /> MSeptic Tank ❑ Cesspool <br /> Dosing Tank Disposal Trenches/Leach Lines <br /> ❑ Multi-compartment Tank M <br /> Capping Fill • <br /> ❑ Seepage Bed ❑ Sand Filter <br /> ❑ 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 acconunodate a standard system or other alternative <br /> onsite'system. ' <br /> There is 2,permit for the septic system ©Yes ['No ['Unknown <br /> • Pen3iit Number(s) CM- — CM-4 i 4 <br /> • Year original septic system installed:11— (YYYZ'), ['No record of installation date <br /> • Dates of subsequent repairs or alterations:•U IU 4,t MJ (YYY Y) <br /> • All plumbing fixtures are connected to the septic system glYes ❑No (Unknown <br /> If you answered"No"or"unknown,"yy�� please describee below: //�'� ( <br /> �C C li1LL (NRt— j�b rt•'4„(� (?� �mt-1r ' tAv <br /> • Additional Comments: <br /> 2. Overall Septic System Status <br /> • Discharge of sewage to the ground surface ❑Yes likNo ]None observed <br /> • Discharge of sewage to surface waters ['Yes R,INo ]None observed <br /> • Sewage backup into plumbing fixtures ❑Yes 1No ['Unknown <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 during the course of this evaluation [ Yes . ❑No. <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 />