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• i <br /> • <br /> Oregon Department.of Environmental Quality •• <br /> • <br /> 1. • General ISystem 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 /> • <br /> • The existing septic system consists of(check all that apply): <br /> Septic Tank ❑ Cesspool • <br /> ❑ Dosing Tank Disposal Trenches/Leach Lines <br /> • <br /> ❑ Multi-compartment Tank • I Capping Fill <br /> ,❑ Seepage Bed ❑ Sand Filter <br /> • ❑ Otber <br /> • Note: Cesspools may be used only to serve existing sewage loads and if failing.only be replaced with <br /> • •a seepage piti system on lots that are too small to accommodate a standard system or other alternative <br /> onsite system. <br /> There is a permit for the septic system t Yes ❑No ❑Unknown <br /> • Permit Number(s) O3— .O 33 0 <br /> • • . Year original septic system installed: � g (YYYY) ❑No record of installation date <br /> • Dates of`subsequent repairs or alterations: (YYYY)• <br /> • • All plumbing fixtures are connected to the septic system ,Yes ❑No .fUnknown <br /> • If you answered"No"or"unknown,"please describe below; . <br /> • Additional Comments: <br /> . i • <br /> • <br /> 2. Overall.Septic'System Status <br /> • • Discharge of sewage to the ground surface ❑Yes ,rNo [None observed • <br /> • • Discharge of sewage to surface waters ❑Yes 6No ❑None observed • <br /> • Sewage Backup into plumbing fixtures ❑Yes ZINo ❑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 Eyes ❑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 />