Laserfiche WebLink
/ r <br /> • ay COLDR?3 <br /> • <br /> rM <br /> ` `�a Existing System Evaluation Report for Onsite ECEIVED <br /> .44, <br /> 4 Wastewater Systems <br /> � , : AU6 14 2024 <br /> State of.Oregon Department of Environmental Quality <br /> ' Onsite Program <br /> -,.. 165;East Seventh Ave, Suite 100 <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): Telephone: <br /> Site Address: 18936 Butteville Rd City: Aurora Zip Code:97002 <br /> County: Marion Lot Size: Acres/Square Feet(circle units) <br /> Legal Description:! 041 W300000100 <br /> Age of wastewateritreatment system . (years) Is there a service contract for system components? <br /> Date the septic tack was last pumped (please attach receipt if available) <br /> Number of people occupying dwelling. 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 /> Date.(MM/DD/YYYY) Signature of Owner,or agent if present <br /> Name of person performing evaluation(please print): Richard Westerlund--NAWT 124931TC <br /> Certification: <br /> ❑ Installer 0 Professional Engineer <br /> ❑ Maintenance Provider ❑ Environmental Health Specialist <br /> D National Association of Wastewater Technicians ❑ Waste Water Specialist <br /> ❑ Other:DEQ approved in writing(please describe) <br /> Certification Number: 33013 <br /> • <br /> Business name Ac'ie Septic and Excavating Email office@ace-septic.com <br /> Business address.P .Box 9177, Brooks, OR 97305 Phone 503-393-1033 <br /> Date of Evaluation:1 D 2(10 9 /tot'1 ..(MM/DD/YYYY) <br /> • i <br /> I hereby certify,bj(my signature,that I meet all of the qualifications required to perform onsite wastewater <br /> system evaluations in the state of Oregon pursuant to 340 71-0155. <br /> -02l foci U)z.c j Z er3y.a'G <br /> Date(MIVI/Dp/YYYY) Signature of Qualified Septic System Evaluator <br /> Page 1 of 8 Updated 12/29/2016 <br />